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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201196
Report Date: 06/21/2023
Date Signed: 06/21/2023 06:31:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230615163239
FACILITY NAME:COGIR OF BRENTWOODFACILITY NUMBER:
079201196
ADMINISTRATOR:HARRISON, DAMIKAFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 84DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Jeffrey 'Jeff' Freeth/Executive Director
and Sylvia Chue/Business Office Manager		TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility has roaches.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10-day complaint visit, and met with Business Office Manager Sylvia Chue. Executive Director (ED) Jeffrey 'Jeff' Freeth arrived after several minutes. LPA informed the reason for visit.

LPA conducted inspection, and obtained copies of resident roster and staff schedule. LPA conducted interviews.

LPA interviewed resident's family member (FM) and 2 staff (S1 and S2) who all stated observing roaches inside the facility. Review of records revealed documentation of facility having roaches. ED indicated that one of the resident's family member complained on June 12, 2023 about the roaches inside the resident's room. Copy of Pest Control Company Invoice dated June 13, 2023 provided by ED to LPA.

.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20230615163239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COGIR OF BRENTWOOD
FACILITY NUMBER: 079201196
VISIT DATE: 06/21/2023
NARRATIVE
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Based on record review and interviews, the preponderance of evidence standard has been met, therefore the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D.

Deficiency was discussed with the ED.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230615163239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COGIR OF BRENTWOOD
FACILITY NUMBER: 079201196
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
-This requirement is not met as evidenced by:
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Corrected.
ED stated pest control was hired recently to eradicate the issue, and will continue the extermination monthly.
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-Based on record review and interview, the license did not comply with the section above for facility having roaches which poses potential health and personal right risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4