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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200241
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:31:44 PM

Document Has Been Signed on 10/01/2024 02:31 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:BRANLEY HOMEFACILITY NUMBER:
079200241
ADMINISTRATOR/
DIRECTOR:		FEDERICO J. MIRANDAFACILITY TYPE:
735
ADDRESS:121 BONITA CTTELEPHONE:
(510) 313-0438
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:MARIFE SIETE, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 10/01/2024 at 11:25AM, Licensing Program Analyst (LPA) C. Fowler arrived to conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Marife Siete and explained the purpose of the visit. Administrator, Federico Miranda arrived at 1:00PM. The Administrator currently holds a certificate (#7033951735) that expires on 11/3/2025.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (5) total bedrooms which four (4) bedrooms are occupied by clients, and (1) one staff room. There are two (2) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 115.6 degrees Fahrenheit. 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 09/18/2024. Emergency Disaster Plan was last posted on 12/08/2023. First aid kit was observed to be complete. Fire drill was last conducted on 09/14/2024.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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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: BRANLEY HOME
FACILITY NUMBER: 079200241
VISIT DATE: 10/01/2024
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Continue from LIC 809

Three (3) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid/CPR certificate. Four (4) Clients records were reviewed all found to be complete.

LPA observed the following deficiencies:
  • At 11:41AM, LPA observed medication in bedroom #3 night stand drawer and in a unlocked lock box located in the refrigerator unlocked.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/08/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2024 02:31 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/01/2024 at 02:03 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: BRANLEY HOME
FACILITY NUMBER: 079200241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 having medication in bedroom #3 drawer and in the refrigerator unlocked which poses an immediate health and safety or personal rights to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Administrator agreed to purchase a lockbox submit a photo to DSS by the POC date. Administrator also agreed to keep all medication locked at all times. During the visit at the facility staff removed the medication from bedroom #3 drawer and locked.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
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