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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220619
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:35:11 PM

Document Has Been Signed on 12/15/2022 12:35 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BRU FAMILY HOME #1FACILITY NUMBER:
191220619
ADMINISTRATOR:LETITIA RAMIREZFACILITY TYPE:
735
ADDRESS:639 EAST AVENUE J-10TELEPHONE:
(661) 945-5057
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 4DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Bibliana Lara "Marie" Bru - LicenseeTIME COMPLETED:
12:35 PM
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On 12/15/22 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by a staff member. LPA observed covid-19 signage, hand sanitizer, PPE supplies and a visitor sign in log. LPA was asked by staff to sign and LPAs temperature was taken. LPA reminded staff member to always wear a surgical mask. LPA later met with the licensee and the purpose of the visit was explained, an entrance interview was conducted.

LPA initiated a physical plant tour; Facility is an Adult Residential Facility which is licensed for 4 clients. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher has a date of service of 5/10/2022. Smoke detectors and carbon monoxide monitors are dual linked and were observed to be functional. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and medication cabinet. Bedrooms are appropriately furnished and have appropriate lighting. The bathroom has soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded areas in the back yard and there are no bodies of water.

No deficiencies issued during today’s visit. Report was signed and delivered, and an exit interview was conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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