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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201196
Report Date: 06/21/2023
Date Signed: 06/21/2023 06:32:10 PM


Document Has Been Signed on 06/21/2023 06:32 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: 84DATE:
06/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jeffrey 'Jeff' Freeth/Executive DirectorTIME COMPLETED:
06:30 PM
NARRATIVE
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On this day, June 21, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230615163239). LPA met with Executive Director (ED) Jeffrey 'Jeff' Freeth, and informed the reason for visit.

LPA toured the facility including but not limited to common areas, ensuite and common bathrooms, dining area, kitchen, activity room, theater. LPA randomly selected total of 5 bedrooms on the first, second and third floors. LPA tested the hot water temperature in one the residents' ensuite bathroom which was measured at 117.3 degrees Fahrenheit.

At 3:24 pm, LPA observed the following in one of the resident's (R1) room: All purpose cleaner; Vicks VapoRub ointment; acid control medication. LPA interviewed staff (S1) who stated R1 is on Medication Management Program. Review of records revealed R1 has dementia and that R1's medications need to be managed. R1's Service Plan indicated R1 is on Medication Management Program.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2023 06:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 A
06/22/2023
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia:
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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ED locked the items.
In addition, ED to conduct in-service training, and submit copy of training topic with attendees signatures by 6/22/23.
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-This requirement is not met as evidenced by:
-Based on observation, records review and interview, the licensee did not comply with the section for having medications, ointments & cleaning supplies accessible to resident which pose immediate risks to person 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
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