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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603121
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:32:48 PM

Document Has Been Signed on 12/15/2022 01:32 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 HOMEFACILITY NUMBER:
197603121
ADMINISTRATOR:BRU, LUIS JRFACILITY TYPE:
735
ADDRESS:1210 EAST DONATELLO STTELEPHONE:
(661) 945-7641
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Susan Bru - staffTIME COMPLETED:
01:40 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 the licensee’s wife, Susan Bru. LPA observed covid-19 signage, hand sanitizer, PPE supplies and a visitor sign in log. LPA was asked to sign in and LPAs temperature was taken. 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 was 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 6/17/2022. Smoke detectors and carbon monoxide monitors are 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 a staff room. Three (3) client bedrooms are appropriately furnished and have appropriate lighting. One (1) bedroom is designated for staf use. There are two (2) bathrooms, both have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area 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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