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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881192
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:13:24 PM

Document Has Been Signed on 02/02/2024 04:13 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:
02/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator, Charmaine SimsTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for a case management visit. LPA was greeted and granted entry by Administrator, Charmaine Sims, who was informed of the purpose of the visit.

An incident had been reported to the licensing agency for suspect abuse on SOC341 for Client #1 (C1). At the time of the visit a walk through, interviews and records reviews were conducted pertaining to the report. No health or safety issues were observed during the time of the visit.

A file review was conducted on the facility, interview with staff and record review of C1's record. LPA found that incident reports had not been sent to licensing for incidents involving C1 such as AWOL, medical visits, and police visits to the facility. Therefore based on the above the facility will receive a deficiency for reporting requirements. Deficiency was reviewed and plan of correction was created with administrator.

An exit interview was conducted where this report along with LIC811, 809D, and appeal rights were reviewed and provided to Administrator, Charmaine Sims.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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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Document Has Been Signed on 02/02/2024 04:13 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/02/2024 at 03:46 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRODIAEA HOUSE
FACILITY NUMBER: 331881192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
80016(b)(1)(E)

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(b) Upon the occurrence...of any of the events specified...a written report...shall be submitted to the licensing agency within seven days...(1) Events...(E)Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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The administrtor agreed to receive training on the reporting requirments and mandated reporting. Written statment is due to the LPA by POC dude date on trainings received and certification.
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This requirment was not met as evidenced by: Based on record review and interview it was found that the facility did not report incident involving C1 to the licening agency. This poses a potential health, saftey or personal rights risk to residents in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
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