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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201067
Report Date: 05/23/2022
Date Signed: 05/23/2022 05:13:09 PM

Document Has Been Signed on 05/23/2022 05:13 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:A FAMILY OF CARE NO. 2FACILITY NUMBER:
079201067
ADMINISTRATOR:WILLIAMS, BRENDAFACILITY TYPE:
740
ADDRESS:2410 SMITH RDTELEPHONE:
(925) 626-4726
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
05/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Brenda Wiliams TIME COMPLETED:
05:45 PM
NARRATIVE
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On 5/23/2022, Licensing Program Analyst (LPA) L.I bo conducted unannounced case management visit. On 5/13/2022 LPA found out that facility had 1 case of covid19 on 5/4/2022, Licensee Brian Friedel stated and confirmed that case was not reported to CCL office. On 5/13/2022 incident report was sent to LPA L.Ibo via email.

LPA observed the following:

ยท Administrator failed to follow CCLD reporting requirements.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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 2
Document Has Been Signed on 05/23/2022 05:13 PM - It Cannot Be Edited


Created By: Leslie Ibo On 05/23/2022 at 04:48 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: A FAMILY OF CARE NO. 2
FACILITY NUMBER: 079201067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2022
Section Cited
CCR
87211(a)(1)

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a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Administrator agreed to review regulation and conduct in-service training with staff on reporting requirements and submit a copy of training to CCL by POC date.
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Based on interview & records review, licensee did not comply with the regulation cited above which poses an potential health and safety risk for persons in care.
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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: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022


LIC809 (FAS) - (06/04)
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