107204087-1-30-2024-24-AS-AWAN-CZYSCM-20240130124546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107204087
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:46:54 PM

Document Has Been Signed on 01/30/2024 12:46 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	BRYLAND ADULT RESIDENTIAL FACILITY, LLC		FACILITY NUMBER:	107204087
ADMINISTRATOR:	WILLIS BRYANT, MIESHUN		FACILITY TYPE:	735
ADDRESS:	510 E. TOWER		TELEPHONE:	(559) 475-0011
CITY:	FRESNO	STATE: CA	ZIP CODE:	93706
CAPACITY:	6	CENSUS: 6	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Administrator, Mieshun Willis-Bryant		TIME COMPLETED:	12:57 PM

NARRATIVE

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On 01/30/2024, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry to the facility. LPA requested to meet with the Administrator. Facility staff contacted Administrator, Mieshun Willis-Bryant via telephone. Administrator arrived a short time later.

LPA conducted a tour of the facility with Administrator. During the inspection the facility appeared clean and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Resident bedrooms appeared clean and had required furnishings and adequate lighting. Residents bathrooms toured. Hot water temperature measured at 107.1 degrees F in the bathroom in the shared room and 106.3 degrees F in the hallway bathroom. Facility kitchen toured. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable food.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguisher is current with a service date of 12/12/2023. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 12/23/2023. Cleaning supplies observed to be locked in a closet. Medications observed to be locked and inaccessible. LPA reviewed client and staff files. Upon review of medication records, LPA found that medication for R4 was not administered as prescribed.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Mieshun Willis-Bryant whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/13/2023: 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.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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 02/13/2024 03:46 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/13/2024 03:34 PM

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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	THIS IS AN AMENDED REPORT: Based on record review, the licensee did not comply with section 80075 when the facility did not maintain a record of centrally stored medications for R1 and was unable to provide documentation for the correct medication during the inspection which is a potential health and safety risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Licensee updated centrally stored medication records to reflect the correct prescription medication. Licensee will also began utilizing the facility communication log to ensure all staff are aware of new medication orders. POC Cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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