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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208973
Report Date: 11/02/2021
Date Signed: 11/02/2021 10:52:44 AM

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:MILLBROOK SENIOR CAREHOMEFACILITY NUMBER:
107208973
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:6720 N MILLBROOK AVETELEPHONE:
(559) 704-6796
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 3DATE:
11/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Elisa Pua, Assistant AdministratorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted a subsequent Case Management visit to discuss information obtained from the annual conducted on 11/02/2021. LPA was met by Assistant Administrator Elisa Pua and stated the purpose of the visit. Administrator Arlene Bautista was unavailable and designated Assistant Administrator.

Licensee did not obtain a building permit prior to the facility’s alteration and storage space.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care

Exit interview was conducted. Licensee was provided with a copy of LIC809, LIC809D and appeal rights.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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: MILLBROOK SENIOR CAREHOME
FACILITY NUMBER: 107208973
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited

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87305 Alterations to Existing Building or New Facilities (a)Prior to construction or alterations, all facilities shall obtain a building permit.
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Based on observation and interview the licensee did not have the facility inspected or obtain building permit to alteration of the facility and storage space, which poses an Immediate health and safety risk to residents in care.
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Type B
11/12/2021
Section Cited

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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Based on observation and interview the licensee did not maintained the facility clean, safe and sanitary. LPA observed three mattress, 2-3 big white boxes, unused furniture and sofas in the patio area, which poses an potential health and safety risk to residents in care.
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Licensee shall remove all items and will maintained the backyard clean, safe and sanitary. Licensee will submit pictures of the backyard by 11/12/2021 to CCL.
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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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