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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201196
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:55:48 PM

Document Has Been Signed on 10/21/2024 03:55 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:COGIR OF BRENTWOODFACILITY NUMBER:
079201196
ADMINISTRATOR/
DIRECTOR:		FREETH, JEFFREYFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 150CENSUS: 120DATE:
10/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:23 PM
MET WITH:Davina Barker, Regional Executive Director
Kuldip Sigh, Health Wellness Director		TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On 10/21/2024 at 2:23PM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct a case management visit regarding an incident report received on 10/16/2024. LPA met with Health and Wellness Director, Kuldip Singh and Davina Barker, Regional Executive Director.

Incident report dated 10/16/2024 revealed that Resident 1 (R1) had an unwitnessed fall resulting in laceration to head and a fractured pelvic.

LPA interviewed Staff one (S1) who stated Staff two (S2) contacted (S1) after responding (R1) pendant call at 10:30AM. LPA was not able to interview Resident 1 (R1) at the time of visit , resident is at skilled nursing facility due to pelvic fracture. LPA was not able to interview Staff two (S2) who was off of work during visit. Interview with Staff 1 (S1) revealed that resident (R1) informed both staff members of walking with walker out of the restroom in her apartment when she suddenly lost her balance and fell. (R1) hit her head on the cabinet resulting in head laceration. (S2) applied pressure on head laceration, stopping the bleeding before paramedics arrived. R1 was transported to the hospital by paramedics. S1 also stated (R1) isn't a fall risk and hasn't had any other incidents pertaining to falls.

LPA collected the following documents: Incident report(s) for October 2024 and Resident roster,

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided to Davina Barker
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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