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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401278
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:01:28 PM

Document Has Been Signed on 09/15/2022 04:01 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:BROTHERS HOME HEALTH CARE, INC.FACILITY NUMBER:
366401278
ADMINISTRATOR:J. DOMINIC MARLIAFACILITY TYPE:
735
ADDRESS:11302 ROCKRIDGE LANETELEPHONE:
(909) 586-5797
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 4CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Vergel Santos, DesigneeTIME COMPLETED:
04:04 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on infection control. LPA met with direct support staff (DSP) who was informed of the nature of the visit. DSP phoned designee Vergel Santos who arrived at the facility during the visit.

During the inspection, LPA and DSP conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was also equipped with sufficient hand hygiene supplies and cleaning and disinfecting provisions. This facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the responsible parties and medical personnel in the event the client presents with any COVID-19 symptoms.

During today's visit, the facility appears to be meeting operational requirements. LPA Bueno observed all bedrooms and bathrooms with appropriate furnishings and working appliances. All utilities are actively used during today's visit. Smoke alarms and carbon monoxide detectors are functioning and charged fire extinguisher was last inspected on 11/18/2021. LPA observed a 2-day supply of perishable food items and 7 days for non-perishables.

LPA observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. ************CONTINUED ON LIC 809-C************
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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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: BROTHERS HOME HEALTH CARE, INC.
FACILITY NUMBER: 366401278
VISIT DATE: 09/15/2022
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LPA did not observe any several COVID-19 related postings throughout the facility. LPA did not observe any emergency contact list and DSP verified that emergency numbers are listed in her phone. Technical violation and technical assistance were issued during today's visit.

An exit interview was conducted where a copy of this report and LIC 9102 TV and LIC 9102 TAs were discussed and provided to Vergel Santos at the conclusion of the inspection
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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