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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881192
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:45:08 PM

Document Has Been Signed on 02/14/2024 02:45 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRODIAEA HOUSEFACILITY NUMBER:
331881192
ADMINISTRATOR:CHARMAINE SIMSFACILITY TYPE:
735
ADDRESS:24595 BRODIAEA AVENUETELEPHONE:
(951) 208-0383
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 3DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Charmaine Sims - AdministratorTIME COMPLETED:
02:54 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Charmaine Sims, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and two (2) clients present. The clients served are ambulatory adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards and contained a sitting area for the clients with shade. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Facility has an infection control plan that met department requirements.



LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

LPA reviewed two (2) staff files and training. All staff have criminal record clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork. LPA inspected the P&I for one (1) client and found no discrepancies.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRODIAEA HOUSE
FACILITY NUMBER: 331881192
VISIT DATE: 02/14/2024
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All client medication was locked in a closet. LPA reviewed client medications for three (3) clients and found all medication listed on MARs and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. Facility conducts fire and earthquake drills monthly. Facility contains emergency supplies in the kitchen pantry and has a first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Charmaine Sims.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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