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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201229
Report Date: 02/21/2023
Date Signed: 02/21/2023 11:11:11 AM


Document Has Been Signed on 02/21/2023 11:11 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:BRENT HOME, LLCFACILITY NUMBER:
079201229
ADMINISTRATOR:REMOLLINO, ARMINAFACILITY TYPE:
735
ADDRESS:3592 MOSSWOOD DRTELEPHONE:
(650) 454-0421
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 0DATE:
02/21/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Armina Remollino Licensee Joel Remollino TIME COMPLETED:
11:30 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Administrator Armina Remollino Licensee Joel Remollino
Interview Method: Telephone interview


On 2/21/2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Marisa HolabirdTELEPHONE: (916) 651-9141
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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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