306003068-5-10-2022-22-AS-ETAA-CEAR78-20220510124555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003068
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:46:08 PM

Document Has Been Signed on 05/10/2022 12:46 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SAN BRUNO HOME		FACILITY NUMBER:	306003068
ADMINISTRATOR:	HEINRICH S.GONZALES		FACILITY TYPE:	735
ADDRESS:	6959 SAN BRUNO		TELEPHONE:	(714) 828-8756
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 5	DATE:	05/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Reynaldo Francisco, Jonel Dapidran, Annamarie Tomilloso		TIME COMPLETED:	12:50 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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Reynaldo Francisco and stated the purpose of this visit. Administrator Annamarie Tomilloso arrived during the visit at 11:20 AM and provided assistance. The facility is a single level structure and licensed for six ambulatory. This facility offers a Level IV- I service. About 10:53 AM LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed four clients in care and two staff members on the duty. LPA toured the interior and exterior portions of the facility. There were six private client rooms. One room was for staff and one of the client rooms was vacant. Vacant room was observed to have cough syrup medication and was immediately removed and locked. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 121.8 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 121.8 degrees Fahrenheit. LPA noticed lights in restroom (2) were not fully operational and requested for them to be replaced. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were on observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Facility was observed to have a 2 car garage used as a kitchen with operating stove, sink, refrigerator and had an operating washer and dryer. Garage also had a restroom with shower for staff use. Kitchen was in good repair with knifes kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAN BRUNO HOME	FACILITY NUMBER: 306003068
	VISIT DATE: 05/10/2022

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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Annamarie Tomilloso and copy of this report was explained and left in the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC809 (FAS) - (06/04)

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