191220719-12-1-2023-31-AS-LCAS-CY4TN7-20231201135217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191220719
Report Date: 12/01/2023
Date Signed: 12/01/2023 01:53:31 PM

Document Has Been Signed on 12/01/2023 01:53 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BRU FAMILY HOME #2		FACILITY NUMBER:	191220719
ADMINISTRATOR:	LUIS BRUI		FACILITY TYPE:	735
ADDRESS:	528 EAST AVENUE J-10		TELEPHONE:	(661) 949-6365
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 6		CENSUS: 4	DATE:	12/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marie Bru		TIME COMPLETED:	02:00 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 Analysts (LPAs) Lorena Casillas and Angela Panushkina arrived at the facility for an unannounced one (1) year Required visit. LPAs arrived at 10:00 am. LPAs were greeted by a caregiver Divina Starks. LPA spoke to the Administrator over the phone and informed her of the purpose of the visit. The Administrator designated Lusia Pattriani to assist LPA’s since Administrator was not available. The Administrator was able to arrive before the end of the inspection at 11:20 am. A tour of the physical plant was conducted with the Caregiver at 10:37 am. The facility has four (4) bedrooms and two (2) and bathrooms currently occupying four (4) clients. One (1) bedroom and one (1) bathroom is designated for staff use only. The facility is Fire Cleared for six (6) ambulatory. Infection control: LPAs reviewed the mitigation plan approved on 3/13/21. The facility is following current infection control recommendations. Living and dining: At 10:40 am, LPAs observed the living room and dining room to be neat and clean. The facility maintains a temperature of 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:46 am. LPAs observed the locked filing cabinet storing client’s medications, staff and client records. Continued....

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BRU FAMILY HOME #2	FACILITY NUMBER: 191220719
	VISIT DATE: 12/01/2023

NARRATIVE

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Kitchen: LPAs conducted a tour of the kitchen around 10:50 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. The knives and sharp objects are kept in the locked staff room. There are two (2) fire extinguishers located in the kitchen and the hallway. The Fire extinguishers were observed to be full and last serviced 05/02/2023.

Bathrooms: LPAs observed client bathroom to have the appropriated wash your hands signs posted. Hot water was tested at 11:00 am and measured at 108.0 degrees F.

Resident Rooms: LPAs observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. LPAs observed the Staff room to be locked.

Laundry: The Laundry room is located in the hallway. LPAs observed the locked closet to have chemicals/hazardous items, PPE supplies, and hygiene items.

Physical environment: LPAs toured the outside area of the facility at 11:05 am. LPAs observed furniture for clients to sit on however the umbrella was put away due to extremely high winds but there are large trees that provide shade. There are no bodies of water on the premises.

Administrative: Annual Fees are current. LPAs collected the LIC 500 and Client Roster.

Continued...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BRU FAMILY HOME #2	FACILITY NUMBER: 191220719
	VISIT DATE: 12/01/2023

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Resident Files: LPAs conducted a file review of resident records to ensure compliance of licensing forms at 11:15 am.

Staff Files: LPAs conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:30 am.

Staff Interviews: At 11:45 am LPA interviewed staff.

Client Interviews: At 11:50 am LPA interviewed clients.

Medications: At 12:00 pm LPA and Administrator reviewed medication and medication records for proper documentation.

LPA Was not able to complete the care tools due to technical issues.

There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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