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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201229
Report Date: 03/14/2023
Date Signed: 03/14/2023 12:50:14 PM

Document Has Been Signed on 03/14/2023 12:50 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: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:
03/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Armina Remollino, Administrator/LicenseeTIME COMPLETED:
01:05 PM
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On 3/14/2023 at 11:15 AM, Licensing Program Analyst (LPA) L. Francisco arrived announced to conduct a Prelicensing Inspection. LPA met with Administrator/Licensee, Armina Remollino. The facility's fire clearance is approved for four (4) ambulatory clients. Facility currently has no clients.

During the prelicensing inspection, LPA toured facility with Administrator/Licensee including but not limited to 3 client's bedrooms, 2.5 bathrooms, multiple dining rooms, staff office, living room and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed in bins. There is sufficient lighting throughout facility. Hot water temperature was maintained at 118 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was observed fully charged and purchased on 12/23/22.

Starting at 12:15 PM, Component III was completed and presented to Administrator/Licensee.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided to Administrator/Licensee.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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