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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881192
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:23:38 PM

Document Has Been Signed on 10/07/2024 04:23 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRODIAEA HOUSEFACILITY NUMBER:
331881192
ADMINISTRATOR/
DIRECTOR:		CHARMAINE SIMSFACILITY TYPE:
735
ADDRESS:24595 BRODIAEA AVENUETELEPHONE:
(951) 208-0383
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 3DATE:
10/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:08 PM
MET WITH:Wanda Walters, DSPTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. LPA met with Wanda Walters, Direct Support Professional (DSP), LPA was informed that three (3) residents currently reside at this facility. There were one (1) staff on duty during the time of the visit.

LPA observed all facility utilities to be on and operating without issue and there were sufficient food supply on hand.

Based on the information obtained during today's visit, the following deficiency are being cited deficiency is cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6, Chapter 1. An exit interview was conducted with DSP Wanda Walters and a copy of this report, LIC809D, 80061 Regulations and appeal rights were provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 10/07/2024 04:23 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 10/07/2024 at 03:10 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: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2024
Section Cited
HSC
80061(a)(e)(1)

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Reporting Requirement: (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including but not limited to section. (e) The items below shall be reported to the licensing agency within 10 working days following the occurence.
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Licensee will submit LIC200 to CCLD and send email to LPA by POC due date.
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(1) The organizational changes specified in Section 80034(a)(2). This requirement is not being met as evidenced by: LPA contacted Licensee and Licensee confirmed that CCLD was not notified of the new Management effective 09/01/2024. This poses a potential health and safety risk to the clients 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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