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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881264
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:40:35 PM

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:BIANCA'S HOME CARE 2FACILITY NUMBER:
331881264
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:12432 BOUGAINVILLEA WAYTELEPHONE:
(714) 507-8040
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 5DATE:
12/15/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Brevet, Dao TIME COMPLETED:
04:40 PM
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On 12/15/2021 Licensing Program Analyst (LPA)’s Venus Mixon and David Cuevas conducted an announced visit for the purpose of a pre-licensing inspection. LPA’s met with Administrator/ Licensee, Brevet Dao and were granted entry. LPA’s took a tour of the interior and exterior of home. The home will be licensed for a total capacity of (6) resident, (5) ambulatory residents and (1) bedridden in either bedroom 2 or 4 only. Delay egress and locked not permitted.

LPA’s were informed that no firearms or ammunition will be kept at facility. The Licensee/Administrator, Brevet Dao has a current Administrator's Certificate (expires 07/29/2022).

LPA’s observed the home as follows: The home is single story 5 bedroom and 2.5-bathroom home with an attached garage next to laundry room. There is dining area next to kitchen with a family room adjacent to the living room. Additionally, staff office is located next to front entrance.LPA's observed a working phone for resident use.

LPA’s observed the bedrooms to be furnished with a bed, dresser, night-stand, and appropriate lighting. The bathrooms have grab bars for resident’s safety and non- skid mats or strips in tubs and showers. LPA’s observed the home to have ample supply of extra towels and linens for resident’s use. Medications will be locked and stored in kitchen area within a closet inaccessible to residents. LPA’s observed a complete first aid kit and manual within medication cabinet. The kitchen was stocked with pots, pans, cook ware, dishes, and silverware. Knives and other sharp items will be locked and stored in kitchen cabinet under locked key.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BIANCA'S HOME CARE 2
FACILITY NUMBER: 331881264
VISIT DATE: 12/15/2021
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Cleaning supplies and disinfectants where observed to be kept in garage, inaccessible to residents under locked key. The hot water was in measured and it was between 105- and 120-degrees Fahrenheit. The smoke detectors were tested and showed to be operable condition and in working condition. Carbon monoxide detector were tested and shown to be in working order. LPA’s observed the Ombudsman poster, personal rights, Administrator certificate and Community Care Licensing complaint poster to be posted. Additionally, LPA’s observed facility to have required single entry point for COVID screening, upon entering facility. LPA’s observed required COVID posting through the facility, and soap and disposable towels in bathrooms for washing hands. Backyard is fenced and has a shaded area with table and chairs for resident’s use. Backyard passageways were free of obstructions and gate exits to be unlocked. At this time facility has shown to have met pre-licensing requirements.

No deficiencies or citations were given during this visit.

COMP lll will be scheduled for a virtual presentation at a later time, due to time constrains.

An exit interview was conducted, and a copy of this report was reviewed with and provided to, Administrator/ Licensee, Brevet Dao.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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