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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201196
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:00:33 PM

Document Has Been Signed on 02/06/2025 04:00 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) 308-9040
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 150CENSUS: 120DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Cayia Peevy, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 02/06/2025 at 1:00PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Cayia Henry Peevy, and explained the purpose of the visit. Administrator certificate #7020769374 expires: 02/25/2026. The facility’s fire clearance was approved for 104 non-ambulatory, 40 ambulatory and 6 bedridden residents. Facility has hospice waiver for twelve (12) residents.

LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs observed a swimming pool behind a locked gate. LPAs toured apartments #117, #235 and #334. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/02/2025. First aid kit was observed to be complete. Fire drill was last conducted on 01/31/2025.

Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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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: COGIR OF BRENTWOOD
FACILITY NUMBER: 079201196
VISIT DATE: 02/06/2025
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Continued from LIC809

LPAs reviewed five (5) staff records, five (5) resident record and they were all complete.

LPA requested the following documents to be submitted to CCLD by 02/13/2025.


· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance

No deficiencies observed 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: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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