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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201196
Report Date: 01/17/2023
Date Signed: 01/17/2023 01:13:57 PM


Document Has Been Signed on 01/17/2023 01:13 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:COGIR OF BRENTWOODFACILITY NUMBER:
079201196
ADMINISTRATOR:MARTINO, AMANDAFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 95DATE:
01/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Amanda Martino, Executive DirectorTIME COMPLETED:
01:30 PM
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LPAs C. Fowler and L. Alexander conducted a face to face Component III presentation on 01/17/2023 starting at 12:55PM. LPAs met with Executive Director, Amanda Martino.

LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted with ED a copy provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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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