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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003068
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:28:44 PM

Document Has Been Signed on 05/31/2024 03:28 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/
DIRECTOR:		HEINRICH S.GONZALESFACILITY TYPE:
735
ADDRESS:6959 SAN BRUNOTELEPHONE:
(714) 828-8756
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 3DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Anna TomillosoTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator (AD) Anna Tomilloso who arrived a short time later and was present for the remainder of the of the visit.

During the inspection all client bedrooms and bathrooms were observed. All client bedrooms had the necessary elements and were in compliance with regulation guidelines.

Client bathrooms were clean and organized. Hot water temperatures were measured between 108.1 - 115.1 degrees Fahrenheit in both client bathrooms. No hazardous items were observed in the client bathrooms, and all grab bars were tightly secured to the wall.

In the kitchen, hazardous cleaning materials are kept locked under the sink. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in a locked cabinet right outside the kitchen across from the front door. Knives and sharp objects are locked in a kitchen drawer. All four burners on the stover were operational.

Client medications and a first aid kit with all the required elements were locked in a cabinet in a hallway near an open office area. There was a fully charged fire extinguisher sitting on the floor below the desk in the open office area, along with a locked filing cabinet with staff and client files.

The backyard was equipped with a table and chairs under a shaded patio area. There’s a basketball court, bikes, exercise bike, and a treadmill for clients to enjoy. The fence in the backyard was leaning back into the neighboring property. On one side of the backyard there were two separate areas with miscellaneous items that need to be disposed of. Some of the items observed were old wheelchairs, old furniture, boxes, some wood and other items.

Continued on LIC809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: 05/31/2024
NARRATIVE
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The garage was organized, and walkways were free of obstruction. There was an extra refrigerator with an additional food supply, a washer, a dryer and additional items like a bike, old clothing that will be donated to the Salvation Army.

Smoke detectors tested operational. The was no carbon monoxide detector in the facility.

An emergency evacuation drill was conducted May 5, 2024 and are conducted monthly.

Deficiencies are being cited as a result of todays visit.

An exit interview conducted, and a copy of this report and appeal rights were provided to Administrator Anna Tomilloso.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/31/2024 03:28 PM - It Cannot Be Edited


Created By: Jerome Haley On 05/31/2024 at 02:28 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAN BRUNO HOME
FACILITY NUMBER: 306003068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/31/2024 03:28 PM - It Cannot Be Edited


Created By: Jerome Haley On 05/31/2024 at 02:52 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: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
Carbon monoxide detectors required; inspection. Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility... The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview confirmation from the Administrator, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/01/2024
Plan of Correction
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The Administrator will by and install a new carbon monoxide detector for the facility. Administrator will email LPA Haley a photo once the new carbon monoxide detector has been installed.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/31/2024 03:28 PM - It Cannot Be Edited


Created By: Jerome Haley On 05/31/2024 at 02:59 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: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(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:
During the inspection with the administrator, LPA Haley observed the backyard fence line leaning over into the neighboring property. In the living room, missing blinds were observed on the sliding glass door that leads to the backyard.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses potential safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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The backyard fence will be replace or repaired by the POC due date. The missing blinds on the sliding glass door will be repaired or replaced. Administrator Tomilloso will email LPA Haley once the corrections have been made.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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