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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003068
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:16:19 PM

Document Has Been Signed on 04/06/2023 03:16 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 HOMEFACILITY NUMBER:
306003068
ADMINISTRATOR:HEINRICH S.GONZALESFACILITY TYPE:
735
ADDRESS:6959 SAN BRUNOTELEPHONE:
(714) 828-8756
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Armand Medalla
Anna Tomilloso		TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Armand Medalla. Staff Wilfredo Pinales was also present. LPA discussed the purpose of the inspection and Administrator (AD) Anna Tomilloso was contacted by phone and arrived at 10:00 a.m.

During the inspection LPAs and Staff Medalla conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a single-story house with six client bedrooms, three bathrooms, and one staff bedroom. Client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. LPAs observed two windows were not screened; a Technical Advisory was given on this date. The back yard has a shaded sitting area. LPAs observed two staff and three clients present. Two out of three bathrooms were observed to be free of debris and mildew; a Deficiency was cited on this date, faucets and toilets were operational. Water temperature tested at 115.7 F degrees.

LPA Gutierrez observed emergency disaster plan and emergency phone numbers listed and posted in kitchen of the facility. Food menu was also posted and visible. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. LPA Gutierrez reviewed facility fire drill log that indicate the last fire drill was on 3/19/23. Stove burners, microwave, washer, and dryer were all inspected; a Deficiency was cited on this date. Sharps were observed locked in kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked and lock is operational. One refrigerated medication was observed to be accessible; a Deficiency was cited on this date. LPAs reviewed three client files and two staff files. LPAs interviewed two clients and two staff. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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 04/06/2023 03:16 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/06/2023 at 02:04 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAN BRUNO HOME
FACILITY NUMBER: 306003068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. Two out of three bathroom sink faucets are coming off their base, Bedroom 3 has a light switch cover but no light switch, third bathroom was observed to have mold, dust, and hair debris, two out of four burners on electric stove in kitchen are inoperable, and four out of four burners on gas stove in garage are inopeable, which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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AD stated that sink faucets would be adjusted to their base, a light switch will be obtained for Bedroom 3, third bathroom will be sanitized, and gas stove in garage will be connected to the kitchen and kitchen electric stove will be disposed of. AD will provide LPA Gutierrez with picture proof of all items addressed via email by POC date.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and admission, the licensee did not comply with the section cited above by building an additional bathroom onto the garage without required fire clearance, which poses an immediate safety risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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AD stated they will submit a new facility sketch and a request for a new fire inspection to approve bathroom addition made to garage by 4/08/23. AD stated they submit the new facility sketch to LPA via email by POC date and fire clearance to CCL once they have been approved.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/06/2023 03:16 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/06/2023 at 02:04 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAN BRUNO HOME
FACILITY NUMBER: 306003068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and staff admission, the licensee did not comply with the section cited above by storing client medication in the kitchen refridgerator in an unlocked box accessible to all persons entering the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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AD brought a locked box during inspection. LPA observed medication is in locked box and lock is operational.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAN BRUNO HOME
FACILITY NUMBER: 306003068
VISIT DATE: 04/06/2023
NARRATIVE
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Based on the observations made during today’s inspection, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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