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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880498
Report Date: 01/02/2024
Date Signed: 01/02/2024 04:19:09 PM

Document Has Been Signed on 01/02/2024 04:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BRACOST VFACILITY NUMBER:
361880498
ADMINISTRATOR:MARQUES, EDIMAR, JR.FACILITY TYPE:
735
ADDRESS:2269 TIFFANY LANETELEPHONE:
(909) 376-3517
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 4CENSUS: 4DATE:
01/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Ileana Marques, LicenseeTIME COMPLETED:
04:20 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Bianca Wolcott made an unannounced visit to the facility to conduct a required annual inspection. LPAs identified themselves to licensee Ileana Marques who was advised of the purpose of the visit. The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. All clients and three staff were present during today's visit.

LPA Wolcott and Mrs. Marques toured the interior and exterior of the facility. The facility has no bodies of water. The backyard has an activity area and covered patio with seating. LPA observed the side gate unlocked and free of obstruction. The facility has a working telephone for use. The facility fire extinguisher was last inspected on 02/23/2023. Staff tested all smoke alarms and carbon monoxide detector. All units were found to be in working order. Medications and facility files are kept in centralized locked areas. Sharps, toxins, and cleaning agents are kept secured.

The following were observed of the physical plant:

Client Bedrooms and Bathrooms: LPA Wolcott and Mrs. Marques observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA and Mrs. Marques observed bathroom appliances were operating in safe and sanitary conditions. The facility keeps a supply of hygiene provision locked.
Kitchen and Dining Areas: LPA and Mrs. Marques inspected the kitchen and found appliances, dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The kitchen countertop and floors were free from debris.
Common (living/activity) areas: LPA observed adequate seating throughout the facility. The facility keeps a supply of activities for the clients. Clients' Rights is posted for visitors to view.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BRACOST V
FACILITY NUMBER: 361880498
VISIT DATE: 01/02/2024
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The following records were inspected:

Client Records: LPA Bueno inspected four client files and found current required documents including but not limited to, signed and dated clients' rights, admissions agreement, physician's report, and Individual Program Plan (IPP).
Staff Records: LPA Wolcott reviewed two staff files and found current first aid and crisis intervention training. The administrator certificate is current.
Centralized Medication: LPAs reviewed four client medications and found that the medication is being administered as prescribed.
LPA Wolcott and Mrs. Marques observed emergency provisions. LPA Bueno observed the facility emergency disaster plan and reviewed required disaster drills.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to licensee Ileana Marques at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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