336426731-5-26-2023-18-AS-CNWE-CS7PPP-20230526112953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426731
Report Date: 05/26/2023
Date Signed: 05/26/2023 11:30:03 AM

Document Has Been Signed on 05/26/2023 11:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BRILLIANCE PLACE		FACILITY NUMBER:	336426731
ADMINISTRATOR:	KYLA DAWN AGUINALDO		FACILITY TYPE:	735
ADDRESS:	1947 BRILLIANCE LANE		TELEPHONE:	(951) 294-0356
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92582
CAPACITY: 6		CENSUS: 5	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Ma Theresa Javier, Caregiver		TIME COMPLETED:	11:35 AM

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On 5/26/2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Janette Romero arrived unannounced at the facility to conduct an annual inspection. LPAs were greeted and granted entry by Caregiver, Ma Theresa Javier who was informed of the purpose of visit. At the time of visit there was 1 staff and 0 clients present. LPAs toured the facility inside and out with Ma Theresa.

Tour included:

Kitchen; LPAs toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans have tight-fitting lids. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 35 degrees Fahrenheit and Freezer was measured at 0 degrees Fahrenheit.

Dining and Livingroom; LPAs toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Home temperature was 73 degrees Fahrenheit.

Hallway; LPAs toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPAs observed medications were labeled and stored in separate bins inside of a locked closet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRILLIANCE PLACE	FACILITY NUMBER: 336426731
	VISIT DATE: 05/26/2023

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Continued from LIC809.

Bathroom; LPAs toured hallway bathroom and observed bathroom to be clean and equipped with grab bar and non-slip mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 108 degrees Fahrenheit.

Bedroom; LPAs toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPAs toured the two garages and observed both garages to be clean.

Laundry; LPAs observed laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for approved capacity. Cleaning supplies are stored away in the staff room and in bathroom cabinet under the sink, inaccessible to clients.

Backyard; LPAs toured the backyard and observed backyard to be clean and furniture in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Refrigerator is large enough to accommodate required perishable.

Records: All staff present have a criminal record clearance on file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 10/06/2024. LPAs inquired about the Infection Control Plan. Ma Theresa stated the Facility does not have an Infection Control Plan, but the facility has a Covid-19 Mitigation Plan. LPA Nwogene informed Ma Theresa that a citation will not be issued today, however, an Infection Control Plan should be developed and provided to LPA by 6/2/2023.

Interview; One staff present was interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Ma Theresa Javier.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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