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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401278
Report Date: 10/13/2023
Date Signed: 10/13/2023 11:54:17 AM

Document Has Been Signed on 10/13/2023 11:54 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
, CA 92507
FACILITY NAME:BROTHERS HOME HEALTH CARE, INC.FACILITY NUMBER:
366401278
ADMINISTRATOR:ELIA MARLIAFACILITY TYPE:
735
ADDRESS:11302 ROCKRIDGE LANETELEPHONE:
(909) 586-5797
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 4CENSUS: 4DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Elia MarliaTIME COMPLETED:
11:56 AM
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Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility to conduct a required annual inspection. LPA identified herself to Staff Saniti Fnu who phoned licensee and who was advised of the purpose of the visit. Licensee Elia Marlia arrived shortly.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients, two of which may be ambulatory. One client and two staff were present during today's visit.

LPA Bueno and Licensee Marlia toured the interior and exterior of the facility. The facility has a shaded patio are and no bodies of water. LPA and Licensee observed that side gates were unlocked and free of obstruction. The facility has a working telephone for use. The facility fire extinguisher was last inspected on 11/28/2022. Licensee and LPA tested smoke alarms and carbon monoxide detector and units were found to be in working order. A locked centralized cabinet is utilized for medications while client and staff files are secured in the office. Sharps, toxins, and cleaning agents are kept locked in a cabinet.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA and Licensee observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility has a supply of additional linens. LPA and Licensee observed bathrooms to be in sanitary condition and sufficient hygiene provisions are available for clients.
Kitchen and Dining Areas: LPA, Staff, Licensee inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA and Licensee observed at least 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 and Licensee observed adequate seating in the common areas. The facility had a supply of activities for the clients. Calendar of activities is posted on the refrigerator.

The following records were inspected:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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 2
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: 10/13/2023
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Client Records: LPA inspected four of four client files and found that it had the required documentation including an admissions agreement, physician's report, and Individual Program Plan (IPP).
Staff Records: LPA reviewed three staff files and found current first aid certifications and training verifications. The administrator certificate will be expiring on 12/1/23.
Centralized Medication: LPA reviewed four of four client medications and found that the medication is being administered as prescribed.
LPA also reviewed current liability insurance, disaster drill logs, and LIC 610, emergency disaster plan.

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 Marlia at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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