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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401612
Report Date: 12/27/2022
Date Signed: 12/27/2022 04:07:19 PM

Document Has Been Signed on 12/27/2022 04:07 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:BROTHERS HOME HEALTH CARE, INC.FACILITY NUMBER:
366401612
ADMINISTRATOR:MARLIA, DOMINIC J.FACILITY TYPE:
735
ADDRESS:240 W. HAWTHORNE STREETTELEPHONE:
(909) 586-5797
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Elia Marlia, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Brother's Home Health Facility unannounced to conduct the Annual Inspection with an emphasis on infection control. LPA introduced self to a staff member outside of the facility, who introduced herself as Elia Marlia, Administrator. LPA explained the purpose of the visit. Administrator granted LPA entry inside facility. Administrator reported the current census is 6 and there are currently no concerns for COVID in the facility. LPA signed in and had temperature taken. COVID station was observed upon entry. Station included a sign in sheet/questionnaire, thermometer and extra PPE.

LPA was provided a space to work, then given a walk through facility. 4 residents and another staff member were present during LPA visit. LPA made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Also, made available in each bathroom.

The facility staff has a plan 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROTHERS HOME HEALTH CARE, INC.
FACILITY NUMBER: 366401612
VISIT DATE: 12/27/2022
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The outdoor and indoor hallways were also free of obstruction. The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers and have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients located in the closets near the rear of the facility. This is also were the emergency supply of PPE, linens, hygiene and emergency supply of food is housed. Fire extinguisher last inspected 11/28/22. Fire and Carbon Monoxide alarms tested and observed to be operational. Fire drills are held every 3 months. Last fire drill 10/17/22. Residents and Medication files reviewed, observed to be orderly and complete.

During inspection, LPA observed an exposed wire coming from a shared wall of the kitchen. Also, hanging wires coming from the ceiling. Administrator stated that an electrician is scheduled to fix on January 3rd, 2022. This was not reported to the office. Technical Violations being issued to address reporting requirements and making alterations to building.

An exit interview was conducted where this report and LIC9102TV were discussed and provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC809 (FAS) - (06/04)
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