197610087-3-8-2024-31-AS-LNCA-D36TCC-20240308133628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610087
Report Date: 03/06/2024
Date Signed: 03/08/2024 01:36:40 PM

Document Has Been Signed on 03/08/2024 01:36 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:	CON CARINO BRAEBURN		FACILITY NUMBER:	197610087
ADMINISTRATOR:	MORALES, LINDA		FACILITY TYPE:	740
ADDRESS:	1744 BRAEBURN RD		TELEPHONE:	(626) 485-7756
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 6	DATE:	03/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Linda Morales- Licensee		TIME COMPLETED:	01:45 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 Analyst (LPA) Leslie Ngo-Castaneda and Perchui 'Milena' Khurshudyan conducted an annual required visit and inspection of the facility. At 9:37 AM MaruyiI Cantin who is a staff at the facility met with LPAs, explained the reason for the visit. At 10:00AM Linda Morales who is the licensee arrived and was explained the reason for the visit. At 10:56 am, with the assistance of administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen and the hallways. The charge date is 3/6/2024. During the visit the facility is at 76 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; one (1) maybe bedridden; approve for two (2) hospice waiver. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen. Bedrooms: There were six (6) bedrooms designated for residents' use. Bedroom #1, bedroom #2, bedroom #3, bedroom #4, bedroom #5, and bedroom #6 are all private use that has only one resident. Residents bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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: CON CARINO BRAEBURN	FACILITY NUMBER: 197610087
	VISIT DATE: 03/06/2024

NARRATIVE

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Bathrooms: There are three and a half (3.5) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 108.8 degrees Fahrenheit for half bathroom located in the hallway beside the kitchen. Bathroom #1 in inside bedroom #6, hot water measured at 110.5 degrees Fahrenheit. Bathroom #2 is beside bedroom #2. Hot water temperature was measured at 118 degrees Fahrenheit. Bathroom #3 is located at inside bedroom #3, hot water measure at 116.8 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPAs toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPAs observed common areas to be very clean and tidy. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPAs obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool, this is fenced up and locked. The garage attached and is used for PPE storage and extra food storage.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located in the garage.

Staff Files: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the kitchen. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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: CON CARINO BRAEBURN	FACILITY NUMBER: 197610087
	VISIT DATE: 03/06/2024

NARRATIVE

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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPAs reviewed client’s files for physician report. Planned activities are offered. Two (2) out of six (6) residents does not have the recent physicians report and TB test (LIC 602) are not signed by residents primary care physician (PCP). LIC 602 has not been returned by the physician to the resident/ facility, because of this a technical violation is given.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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