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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200220
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:58:18 PM

Document Has Been Signed on 06/02/2023 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GARDEN BRENTWOODFACILITY NUMBER:
079200220
ADMINISTRATOR:JACKIE BAILEYFACILITY TYPE:
775
ADDRESS:1191 CENTRAL BLVD., STE. BTELEPHONE:
(925) 626-3642
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 30CENSUS: 15DATE:
06/02/2023
TYPE OF VISIT:CollateralANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Ciara Vasquez, Program CoordinatorTIME COMPLETED:
03:00 PM
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On 06/02/23 around 02:25 PM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a case management for a restricted healthcare condition request for Client #1 (C1) that resides at an Adult Residential Facility (ARF). LPA met with Ciara Vasquez, Program Coordinator (PC), and explained the purpose of the visit.


LPA L. Holmes conducted a joint visit with Program Clinical Consult (PCC), Witnesses (W1, W2), toured the facility with PC, interviewed staff, reviewed records, and observed the compliancy of C1's gastrostomy care. ISP, MAR and feeding schedule provided for C1.

LPA requested the following documents be submitted to CCLD by 06/09/23: for Staff members training records, license of contracted nurse, and sign-in sheet for training attendees.


Exit interview conducted and a copy of this report was provided to PC.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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