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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200220
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:42:44 PM

Document Has Been Signed on 08/19/2024 03:42 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GARDEN BRENTWOODFACILITY NUMBER:
079200220
ADMINISTRATOR/
DIRECTOR:		JACKIE BAILEYFACILITY TYPE:
775
ADDRESS:1191 CENTRAL BLVD., STE. BTELEPHONE:
(925) 626-3642
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 30CENSUS: DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:53 AM
MET WITH:Ciara Vasquez, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
03:49 PM
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On 08/19/2024 at 10:53am, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an Annual 1-Year required inspection. LPA met with Ciara Vasquez, Program Coordinator, and explained the reason for the visit. The facility's fire clearance was approved for 30 Non ambulatory
Clients.

LPA inspected the facility with Program Director, which included but not limited to the bathrooms, kitchen, and common areas of the facility. LPA observed the facility to be free of odor, clean and in good repair. There is a comfortable room temperature of 77 degrees Fahrenheit for clients in care. Grab bars were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 116.9 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. Emergency disaster plan last updated 11/15/2023. Fire extinguisher last services 01/25/2024 Fire drill last conducted 02/13/2024. First aid kit was checked and is complete.

LPAs reviewed five (5) staff files. LPAs reviewed five (5) clients, and all were current and complete.

Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GARDEN BRENTWOOD
FACILITY NUMBER: 079200220
VISIT DATE: 08/19/2024
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 08/26/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610D Emergency Disaster Plan including infection control plans
  • LIC 9020 Clients' Roster

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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