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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201196
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:40:02 PM


Document Has Been Signed on 12/14/2023 02:40 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:FREETH, JEFFREYFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 111DATE:
12/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kuldip Singh, Health and Wellness DirctorTIME COMPLETED:
02:50 PM
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On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a resident incident that occurred on 12/1/23. LPA spoke with Kuldip Singh, Health and Wellness Director and explained the purpose of the visit.

LPA received an unusually incident report (UIR) regrading a resident had an un-witnessed fall during happy hours led to a fracture hip. Resident had hip surgery and is in a skill nursing for recovering. Kuldip spoke with resident daughter on 12/4/23 to get updates on resident.

LPA interviewed Kuldip regrading the follow up with the resident current condition. Resident is currently at the rehab recovering, and while return after facility do an evaluation. Prior to the fall resident was very independent, self-care, and self-med with no assisted devices.

LPA obtained: Staff roster, resident roster, resident progress notes, and a copy of the incident report that faxed to CCLD on 12/5/23.


No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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