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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403457
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:30:30 PM

Document Has Been Signed on 08/18/2023 04:30 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 #2FACILITY NUMBER:
336403457
ADMINISTRATOR:INGRID E. BRILLOFACILITY TYPE:
735
ADDRESS:13830 MANGOWOOD DR.TELEPHONE:
(951) 243-9727
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 2DATE:
08/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Christopher AlcaydeTIME COMPLETED:
05:00 PM
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On 8/18/2023, Licensing Program Analyst (LPA) Janette Romero conducted a Case Management visit to document a death mentioned to LPA during the annual visit.
During a tour of the facility's interior and exterior, LPA was informed by Caregiver Remedios Pascua that a client was taken to the hospital and had passed away on 8/3/2023. The facility submitted Unusual Incident/Injury Reports (LIC 624s) concerning Client #1's (C1's) hospital admission and death to Community Care Licensing Division's (CCLD) Riverside Regional Office via fax/email, in a timely manner. Facility to submit a Death Report (LIC 624A) and a copy of C1's Death Certificate to CCLD via fax/email.

LPA requested copies of the following documents:
  1. ID/Emergency Information
  2. Admission Agreement
  3. Physician's Report
  4. Psychiatric and Medical Notes/Orders
  5. Resident Appraisal and Service Plan
  6. Progress Notes
  7. Medication Records
  8. Personal Property Record
  9. Weight Record
  10. Laboratory Orders
A copy of this report was discussed and provided to Administrator Alcayde.
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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