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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403457
Report Date: 08/23/2023
Date Signed: 08/23/2023 12:33:39 PM

Document Has Been Signed on 08/23/2023 12:33 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:
08/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Christopher AlcaydeTIME COMPLETED:
12:45 PM
NARRATIVE
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On 8/23/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a follow up Case Management visit and issue a deficiency regarding a previous visit on 8/18/2023, where LPA found that various incidents had taken place at the facility that required to be reported to Community Care Licensing's Riverside Regional Office. Licensee was unable to provide proof of reports submitted to the office via fax. As a result, LPA issued a deficiency. LPA also requested copies of Inland Regional Center's Individual Program Plan and Medication Administration Record for Client #1, missing from the visit conducted on 8/18/2023.

During today's visit, LPA conducted a tour of the facility's interior and exterior and did not observe any issues or concerns. LPA was greeted and granted entry by Caregiver Remedios Pascua and Administrator Christopher Alcayde arrived during the visit and provided LPA with copies of the requested documentation.

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: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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Document Has Been Signed on 08/23/2023 12:33 PM - It Cannot Be Edited


Created By: Janette Romero On 08/23/2023 at 11:35 AM
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: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2023
Section Cited
CCR
80061(a)

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(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. This requirement was not met as evidenced by:
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During LPA's visit, Licensee adjusted the facility's fax machine settings to print a fax transmission report to verify that a fax message was successfully delivered to the sender. Licensee agreed to keep copies of fax receipts when submitting reports to CCLD.
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Based on observation and interview, Licensee did not comply with the section cited above due to Licensee not being able to provide proof of reports submitted to CCLD via fax. This poses a potential risk to the health, safety or personal rights of 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
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