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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004574
Report Date: 10/28/2021
Date Signed: 10/28/2021 10:02:01 AM

Document Has Been Signed on 10/28/2021 10:02 AM - 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:BREWSTER HOMEFACILITY NUMBER:
306004574
ADMINISTRATOR:EVELYN PASCUALFACILITY TYPE:
735
ADDRESS:1237 W. BREWSTER AVE.TELEPHONE:
(714) 535-3976
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Edgardo PascualTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Administrator Edgardo Pascual. LPA explained the reason for the visit. Facility has 6 bedrooms, 3 bathrooms and a 2 car attached garage. One bedroom is used for staff. LPA and Administrator toured the facility. All smoke detectors/carbon monoxide detectors tested operational. LPA observed the fireplace in the living room is screened. LPA observed the facility has a 2 day perishable and 7 day non-perishable food supply on hand. LPA observed the cleaning supplies are kept locked under the kitchen sink. LPA observed the knives are kept locked in a kitchen drawer. All client bedrooms had the required furnishings. LPA observed the medications are kept locked in the pantry in the hallway. Fire extinguishers are fully charged. LPA toured the backyard. The backyard has a covered patio with a seating area. The shed in the backyard is kept secured and is used for storage. Both exits gates in the backyard are operational. The garage is used for storage and kept locked. Facility has a mitigation plan that is pending review. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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