107208973-10-12-2023-24-AS-MFLS-CWJULM-20231012154058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208973
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:41:05 PM

Document Has Been Signed on 10/12/2023 03:41 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:	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:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Elisa Pua		TIME COMPLETED:	04:00 PM

NARRATIVE

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On 10/12/23 at 12:35PM, Licensing Program Analyst (LPA) M. Flores arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and met with Assistant Administrator Assistant, Elisa Pua.

LPA tour the inside and outside of the facility. The facility was observed to be at a comfortable temperature of 73 degrees F, clean, in good repair, and no passageway obstructions. Cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room. Sharps and medications are kept in a locked cabinet next to the kitchen. All bedrooms were observed to have required furnishings and with adequate lightening. LPA observed three bedrooms. Bathroom is properly equipped, and the hot water temperature was tested at 117.9 degrees F. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of staff and client’s files were reviewed. First Aid checked and fully stocked.

LPA observed the following deficiency:

1. There was not an adequate supply of perishable and non-perishable foods.

A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D.

Continue 809-C

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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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Document Has Been Signed on 10/12/2023 03:41 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: MILLBROOK SENIOR CAREHOME	FACILITY NUMBER: 107208973
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)

General Food Service Requirements

(b) The following food service requirements shall apply: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited 88555(b) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to maintain 2 day supply of perishable & 7 days supply of non perishable food in addition to food required to make/serve meals & snacks at all times. Licensee will submit a copy of complete grocery receipt to Fresno CCL by POC due date.

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: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MILLBROOK SENIOR CAREHOME	FACILITY NUMBER: 107208973
	VISIT DATE: 10/12/2023

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The following updated forms are to be submitted to CCL by 10/20/23:

LIC308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9282, LIC999, Administrator certificate, and control of property.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with staff. A copy of this report and appeal rights were discussed and left with Assistant Administrator whose signature on this form confirms receipt of these document.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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