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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204087
Report Date: 01/23/2023
Date Signed: 01/23/2023 10:43:36 AM

Document Has Been Signed on 01/23/2023 10:43 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BRYLAND ADULT RESIDENTIAL FACILITY, LLCFACILITY NUMBER:
107204087
ADMINISTRATOR:WILLIS BRYANT, MIESHUNFACILITY TYPE:
735
ADDRESS:510 E. TOWERTELEPHONE:
(559) 475-0011
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY: 6CENSUS: 6DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Facility Staff, Martha GalindoTIME COMPLETED:
10:07 AM
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This is an amended report. On 01/23/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection - infection control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator via telephone. Administrator is not available to meet for this inspection. LPA received verbal permission to meet with Facility Staff, Martha Galindo. Facility has one central entrance and exit. Facility has implemented a symptom screening / temperature check for visitors

Facility tour conducted with Facility Staff. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA did not observe a 7-day supply of non-perishable foods or a 2-day supply of perishable foods. Per staff, another staff member is en route to the facility to restock facility supplies. LPA observed a unlatched, locking device on the kitchen refrigerator and the pantry door to be equipped with a locking device, preventing access to residents in care. LPA observed an adequate supply of PPE and cleaning supplies.

There are 2 private rooms and 2 shared bedrooms at the above facility. Beds observed to be at least 6 feet apart and 3 feet apart with head to toe orientation. Liquid soap observed in the bathroom and paper towels were not observed in the bathrooms. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply.

CONTINUED TO 809C
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BRYLAND ADULT RESIDENTIAL FACILITY, LLC
FACILITY NUMBER: 107204087
VISIT DATE: 01/23/2023
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LPA is requesting the following documents be submitted to the Fresno CCL office by 02/06/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview conducted. A copy of this report was discussed and provided to Facility Staff, Martha Galindo, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 01/23/2023 10:09 AM


Created By: Alexandria Walton On 01/23/2023 at 09:20 AM
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BRYLAND ADULT RESIDENTIAL FACILITY, LLC
FACILITY NUMBER: 107204087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023


LIC809 (FAS) - (06/04)
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