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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880499
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:05:12 PM

Document Has Been Signed on 11/08/2022 02:05 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRACOST IVFACILITY NUMBER:
361880499
ADMINISTRATOR:RAFAEL ALPIZARFACILITY TYPE:
735
ADDRESS:1989 MESA DRIVETELEPHONE:
(909) 376-3517
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 5DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Raphel Alpizar, CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Amber Coleman and Anna Bueno made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA were met, greeted and invited inside facility by staff member Raphel Alpizar (S1) S1 took LPAs temperature as asked to sign in to log book. It was there, LPA observed offered PPE, hand sanitizer, and disinfectant supplies. Staff were observed wearing proper PPE. Administrator Ileana Marques was also present during visit. S1, Administrator and LPAs discussed the purpose of the visit. The facility was observed to cleanly, free of debris and in comfortable temperature.

S1 and Administrator walked through facility and backyard. S1 reported no current cases of COVID in facility. All staff and residents have been vaccinated. Proper signs and signs regarding infection control were observed throughout facility. The facility staff has a plan in place to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift.

LPA observed no health and safety concerns while walking through facility. The client rooms had the required furniture and sufficient lighting. The facility had a supply of additional linen and extra hygiene items and paper supplies for the resident. Fire and carbon monoxide alarms were tested and operational. Fire extinguisher last inspected 1/20/22. Medications, chemicals and sharp objects were observed being kept in secure locations.


Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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