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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201229
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:56:50 PM

Document Has Been Signed on 03/05/2025 01:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BRENT HOME, LLCFACILITY NUMBER:
079201229
ADMINISTRATOR/
DIRECTOR:		REMOLLINO, ARMINAFACILITY TYPE:
735
ADDRESS:3592 MOSSWOOD DRTELEPHONE:
(925) 233-7346
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 1DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Jonathan Bentulan, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 03/05/2025 at 12:40PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced annual required inspection. LPA met with Jonathan Bentulan, House Manager, and explained the purpose of the visit. Administrator currently holds an Administrator Certificate #7035967735 which expires on 05/28/2026. LPA toured the facility with Jonathan Bentulan. The facility’s fire clearance was approved for Four (4) ambulatory clients.


LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of three (3) total bedrooms, two and half (2 ½) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/18/2024. Emergency Disaster Plan was last posted on 03/01/2025. Fire drill was last conducted on 03/01/2025. First aid kit was observed to be complete.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRENT HOME, LLC
FACILITY NUMBER: 079201229
VISIT DATE: 03/05/2025
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Continued from LIC809


Three (3) staff records reviewed and complete. One (1) client record reviewed and complete. LPA also reviewed P & I during visit.


The following forms to be updated and submitted to CCLD by 03/12/2025:
  • LIC 500 Personnel Report (updated)
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC610D Emergency Disaster Plan
  • LIC308 Designation of facility responsibility
  • Updated Facility Sketch


No deficiencies cited during visit.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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