107208973-11-1-2021-24-AS-LCAA-C8CTVH-20211101150357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208973
Report Date: 11/01/2021
Date Signed: 11/01/2021 03:04:13 PM

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 CAREHOME		FACILITY NUMBER:	107208973
ADMINISTRATOR:	BAUTISTA, ARLENE		FACILITY TYPE:	740
ADDRESS:	6720 N MILLBROOK AVE		TELEPHONE:	(559) 704-6796
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 3	DATE:	11/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Elisa Pua, Assistant Administrator		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA was met by Assistant Administrator Elisa Pua and stated the purpose of the visit. Administrator Arlene Bautista was unavailable and designated Assistant Administrator to complete the annual inspection. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned. Hand sanitizer was readily available to clients and visitors. Social distancing is maintained in the common areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the kitchen and bathroom sinks. The exterior tour was conducted. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Residents wear masks when away from the community. Client’s files have updated emergency contact information. Exit interview was conducted.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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
	VISIT DATE: 11/01/2021

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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):

· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 11/08/2021

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC809 (FAS) - (06/04)

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