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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201196
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:59:53 PM


Document Has Been Signed on 02/02/2023 01:59 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:HARRISON, DAMIKAFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 93DATE:
02/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amanda Martino, Administrator TIME COMPLETED:
02:15 PM
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On 02/02/2023, Licensing Program Analysts (LPA) L. Ibo conducted an unannounced case management. LPA met with Administrator, Amanda Martino.

While LPA was at the facility conducting another visit, Administrator self-reported an incident from 02/01/2023 and handed an incident report to LPA.

Based on the report, on 02/01/2023, at around 10:00AM R1 reported to front desk staff (S2), that her jewelry's were missing and taken from her apartment. S2 informed Administrator about the incident. Based on interview with Administrator, facility is currently conducting their own investigation. Police report was filed. R1’s family was notified.

Due to pending investigation by Police and facility staff, LPA do not have available documents currently. LPA will return to the facility as soon as all information are received.

Exit interview conducted with Kudip Singh and Amanda Martino. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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