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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200367
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:25:23 PM

Document Has Been Signed on 07/07/2022 04:25 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:BRENTWOOD CARE HOMEFACILITY NUMBER:
079200367
ADMINISTRATOR:GARRY MALABATOFACILITY TYPE:
740
ADDRESS:1611 MINNESOTA AVENUETELEPHONE:
(925) 240-7628
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Gary and Rose Malabato, Administrator/LicenseeTIME COMPLETED:
04:40 PM
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On 7/7/2021 at 12:00 PM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Licensee Rose Malabato and Administrator Gary Malabato. LPA observed 4 residents at the the facility.

LPA inspected the facility inside and outside. No bodies of water. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. LPA observed COVID-19 posters posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing & infection control. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Facility has enough supplies of PPEs, paper supplies and hygiene supplies.


...Continue to LIC809C....
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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 3
Document Has Been Signed on 07/07/2022 04:25 PM - It Cannot Be Edited


Created By: Leslie Ibo On 07/07/2022 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRENTWOOD CARE HOME
FACILITY NUMBER: 079200367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in LPA observed 2 pair of scissors accesible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2022
Plan of Correction
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Cleared and corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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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: BRENTWOOD CARE HOME
FACILITY NUMBER: 079200367
VISIT DATE: 07/07/2022
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LPA observed the following:

· 2 pair of scissors were observed to be accessible to residents in care – Corrected during LPA visit.
· LPA requested for additional PPE supplies (N95)

Medications are centrally stored in a locked area that is inaccessible to clients and refilled least every 30 days. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 75 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed to be at zero degrees Fahrenheit. Smoke and Carbon monoxide detectors were operational.



Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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