336403457-8-18-2023-18-AS-JROO-CUTVG3-20230818162451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403457
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:24:56 PM

Document Has Been Signed on 08/18/2023 04:24 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BRILLO ADULT RESIDENTIAL CARE #2		FACILITY NUMBER:	336403457
ADMINISTRATOR:	INGRID E. BRILLO		FACILITY TYPE:	735
ADDRESS:	13830 MANGOWOOD DR.		TELEPHONE:	(951) 243-9727
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 4		CENSUS: 2	DATE:	08/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Christopher Alcayde		TIME COMPLETED:	05:00 PM

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On 8/18/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Remedios Pascua who was informed of the purpose of visit. Administrator Chistopher Alcayde arrived during the inspection.

During the visit, there was one (1) staff and two (2) clients present at the facility.

The facility is approved to care for four (4) non-ambulatory clients and serves adults ages 18-59. The facility is made up of three (3) client rooms, two (2) client bathrooms, a kitchen, two (2) living rooms, and garage. LPA toured the facility's interior and exterior with Caregiver Pascua.

During the visit, LPA observed the following:

Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Knives/sharps are secured in a locked kitchen drawer. Cleaning solutions are secured in a cabinet under the kitchen sink.

Dining/Living room: LPA toured the dining and living/family rooms area. LPA observed areas to be clean and furniture in good condition.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRILLO ADULT RESIDENTIAL CARE #2	FACILITY NUMBER: 336403457
	VISIT DATE: 08/18/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications are secured in a locked closet near one of the living rooms. LPA reviewed physical medications for Client #1 and Client #2 as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. No discrepancies discovered.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting. LPA observed Client #1's mattress is soiled and Client #1's room releases a strong urine odor. Deficiency cited.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with non slip mats. The hot water temperatures measured at 108- and 109-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.
Laundry/Garage: Washing machine and dryer are all in good repair and stored in the garage. Emergency food supplies, water, additional linen, and incontinent supplies are stored in the garage.

Records: Staff present has a criminal record clearance on file and is associated to the facility. Staff training is up to date.

Yard/Outside Area: Covered patio seating is available for the clients. Indoor and outdoor passageways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Carbon monoxide/Smoke detectors: Carbon monoxide and smoke detector was tested and functioning properly. Fire extinguisher is charged and mounted near entrance hallway.

During today's visit, LPA observed a deficiency faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Alcalde along with an LIC809-D and Appeals Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/18/2023 04:24 PM - It Cannot Be Edited

Created By: Janette Romero On 08/18/2023 at 03:49 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: BRILLO ADULT RESIDENTIAL CARE #2	FACILITY NUMBER: 336403457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(1)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing a soiled mattress in Client #1's bedroom, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Facility agreed to clean or replace soiled mattress observed in Client #1's bedroom and provide proof of correction to CCLD by close of business on POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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