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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201149
Report Date: 05/13/2024
Date Signed: 05/13/2024 01:32:00 PM


Document Has Been Signed on 05/13/2024 01:32 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PROMESA, MILLBROOK HOUSEFACILITY NUMBER:
107201149
ADMINISTRATOR:J. MANZANARES,A.VARGASFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:25CENSUS: 5DATE:
05/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Arlene VargasTIME COMPLETED:
01:00 PM
NARRATIVE
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On 05/13/2024, Licensing Program Analyst (LPA) Tamara Melikian conducted an unannounced case management for the above STRTP. Met by Residential Program Director Arlene Vargas.

The purpose of the inspection is to issue a deficiency for incident reports not being submitted timely to the Department after the receipt of the 24 hour initial notice.

Deficiency on the attached page.

A copy of this report is given to Residential Program Director, Arlene Vargas.
SUPERVISOR'S NAME: Lourey BartolomeTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Tamara MelikianTELEPHONE: (559) 974-5520
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
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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Document Has Been Signed on 05/13/2024 01:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: PROMESA, MILLBROOK HOUSE
FACILITY NUMBER: 107201149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2024
Section Cited
CCR
80061(b)

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Reporting Requirements 80061(b).
A written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by:
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Incident reports were received and a written warning was completed on the Administrator. Documents received and deficiency cleared on this date.
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Based on record review conducted by this LPA, written incident reports were not submitted to the department within 7 days which presents a potential Health, Safety, or Personal Rights risk to the clients 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: Lourey BartolomeTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Tamara MelikianTELEPHONE: (559) 974-5520
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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