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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602826
Report Date: 05/17/2022
Date Signed: 05/17/2022 11:43:22 AM

Document Has Been Signed on 05/17/2022 11:43 AM - 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 JR FAMILY HOME #2FACILITY NUMBER:
197602826
ADMINISTRATOR:BRU, LUIS JR.FACILITY TYPE:
735
ADDRESS:44950 CAMOLIN AVENUETELEPHONE:
(661) 522-5230
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Luis Bru Jr, AdministratorTIME COMPLETED:
11:55 AM
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At 10:05am, Licensing Program Analyst (LPA) Shira Stamps arrived at the above facility for an unannounced one (1) year Required visit. LPA knocked on the door, but there was no answer. At 10:10am, LPA called the Administrator who stated he was on his way to the facility. The Administrator arrived at 10:25am, and LPA informed the Administrator of the purpose of the visit. All clients were away from the facility at the time of the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/20/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and sanitizer was made available.

A tour of the physical plant was conducted with the Administrator at 10:27 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) clients. One (1) bedroom and one (1) bathroom is designated for staff use only.

Food Inspection
LPA conducted a tour of the kitchen around 10:27 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. There is one (1) fire extinguishers located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 06/15/21.

Laundry
LPA observed no chemicals/hazardous items located in laundry area.
CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BRU JR FAMILY HOME #2
FACILITY NUMBER: 197602826
VISIT DATE: 05/17/2022
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Living and dining
At 10:29am, LPA observed the living room and family room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The smoke detectors were tested and observed to be operational at 10:45am. There was no carbon monoxide found in the facility. At 10:55am the Administrator called a staff member to buy a new carbon monoxide detector. At 11:21am the Administrator installed the new carbon monoxide detector in the hallway.
Hallway
At 10:30am, LPA observed all knives and sharp object being locked in the hallway closet inaccessible to clients in care. LPA also observed chemicals, cleaning supplies, medications, first aid kit, and resident files locked in the hallway closet.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 10:36am LPA observed all bathrooms to have non-skid matts, and the appropriated wash your hands signs posted. Hot water was tested at approximately 10:50am and measured within regulation at 118.8 degrees F.

Garage
At 10:43am, LPA observed the garage to be detached from the facility and currently being used for storage and extra PPE supplies. The garage is locked at all times and inaccessible to clients in care.

Physical environment
LPA toured the outside area of the facility at 10:40am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Administrative: Annual fee is current.

An exit interview was conducted and citation issued. A copy of this report and appeal rights were given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2022 11:43 AM - It Cannot Be Edited


Created By: Shira Stamps On 05/17/2022 at 11:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BRU JR FAMILY HOME #2
FACILITY NUMBER: 197602826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
1503.2 Carbon Monoxide detectors required.
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the facility did not contain a carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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At 11:21am, the Administrator installed the new carbon monoxide detector in the hallway.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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