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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602826
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:42:29 PM

Document Has Been Signed on 06/01/2023 04:42 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 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: 4DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Luis Bru Jr, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shira Stamps arrived at 11:00 am and knocked on the door, but there was no answer. The Administrator Luis Bru Jr was contacted over the phone and met with LPA at 11:30 am for an annual required inspection.

Entrance interview conducted.

LPA, and the Administrator conducted a tour of the facility at 11:40 am. The following was observed:

LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residents

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture to be in good repair. The facility maintains a comfortable temperature at 70 degrees F. LPA observed fire extinguishers to be full and last serviced on 6/2/22.

Resident rooms: LPA toured the resident rooms and bathrooms at 11:50 am. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blankets, which are in good condition. There is at least one chair, night stand and sufficient lighting for each resident. At 11:51 LPA observed laundry detergent located in the closet of room #1. The Administrator immediately removed the detergent and placed in the locked hallway closet.

At 11:55am LPA observed Windex unlocked in the staff bathroom accessible to residents in care. At 12:00 pm LPA observed all smoke alarms and carbon monoxide to be in working condition.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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Document Has Been Signed on 06/01/2023 04:42 PM - It Cannot Be Edited


Created By: Shira Stamps On 06/01/2023 at 04:28 PM
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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 windex was found in the unlocked staff bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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The Administrator stated he will conduct an inservice training with all staff member reviewing over the regulation section cited above. The Administrator will provide LPA with a staff sign in sheet, and training materials by the POC due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one (1) out of three (3) staff files reviewed one staff members first aid and CPR certification expired on 5/01/23 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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The Administrator stated the staff member will not return to work until the certification is renewed. The Administrator will provide a new certificate to LPA by the POC due date.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BRU JR FAMILY HOME #2
FACILITY NUMBER: 197602826
VISIT DATE: 06/01/2023
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Bathrooms: LPA observed all other rooms to have appropriate grab bars and non-skid mat in the bathroom. LPA observed that residents have sufficient amounts of supplies for personal hygiene which is provided by the Licensee. The hot water measured at 11:55am at 121.8 degrees F. The Administrator adjusted the hot water tank, and LPA remeasured the water and it measured within regulation of 105 degrees F and 120 degree F.

Laundry service: There is enough linen available to change weekly or more if need.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No pools or bodies were observed on the premises.

Food Inspection: LPA conducted a food inspection tour at 11:40 am. LPA observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

Personnel Records: LPA reviewed 3 staff records. Staff are fingerprint cleared. LPA observed the Administrator certificate to be valid until 09-24-2019. One (1) out of three (3) staff members 1st aid and CPR certification is expired. The Administrator stated the staff member will not return to work until the certificate is renewed.

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report.

Appeal rights issued. Exit interview conducted. Copy of report delivered to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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