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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336407797
Report Date: 06/15/2022
Date Signed: 06/15/2022 09:35:10 AM


Document Has Been Signed on 06/15/2022 09:35 AM - 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:BRENTWOOD, THEFACILITY NUMBER:
336407797
ADMINISTRATOR:RUDY VILLARFACILITY TYPE:
740
ADDRESS:27-789 SAN MARTINTELEPHONE:
(760) 325-4133
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 4DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Fem Navarro, CaretakerTIME COMPLETED:
09:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Caretaker Fem Navarro and explained the purpose of today's visit. There were 4 clients inside the facility at the time of visit. Licensee Rudy Villar and House Manager Imelda Villar arrived inside the facility during the visit.

During today’s visit, LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions also a 30 day supply of Personal Protective Equipment (PPE).

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19. When and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas.

The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Continued on LIC809-C
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: BRENTWOOD, THE
FACILITY NUMBER: 336407797
VISIT DATE: 06/15/2022
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During the tour of the facility, LPA observed medications kept in an unlocked closet. Thus a Type B citation was issued per Title 22, Division 6, Chapter 1 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was discussed with and provided to Ms. Villar along with a copy of the LIC809-D and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/15/2022 09:35 AM - It Cannot Be Edited

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: BRENTWOOD, THE
FACILITY NUMBER: 336407797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
(k) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of an unlocked medication closet, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
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Licensee agrees to ensure medication closet is kept locked. Licensee further agrees to provide training to staff and submit a signed understanding of all staff via email on the cited regulation by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
LIC809 (FAS) - (06/04)
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