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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401612
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:12:40 PM

Document Has Been Signed on 12/07/2023 02:12 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: 0DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:N/ATIME COMPLETED:
02:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Brother's Home Health Care, Inc. Adult Residential Facility to conduct the Annual Inspection. LPA knocked on the door and was greeted and invited inside the facility by Administrator, Elia Marlia. LPA introduced self and stated the purpose of the visit, then provided a space to work. Administrator, Elia Marlia accompanied LPA Coleman on a tour of the facility, inside and outside, and observed the following:

Facility: The facility was initially licensed on 10/1/97, approved for a capacity of 6 residents. Two, (2) or which can be ambulatory and four, (4) non-ambulatory. Also approved for the hearing impaired. The facility also maintains partnership with the Inland Regional Center; designated level L3. The facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL).

Physical Plant: The facility's temperatures were observed to be comfortable. The facility has sufficient lighting provided by various lamps, lighting and night-lights throughout the facility. The facility is equipped with adequate smoke alarms, carbon monoxide detectors and fire extinguishers which were tested and found operable. The facility's fire extinguisher was observed fully charged and last inspected December of 2023.Administrator reports that the facility conducts fire drills every four months. Last fire/disaster drill conducted August 2023. LPA observed 4 resident rooms. Each room included adequate seating, sufficient lighting with storage space. Each resident room also contained a backpack of emergency supplies. The facility has 2 resident restrooms. Each bathroom was equipped with adequate amounts of hand soap and paper towels, proper lighting, labeled and separately stored hygiene supplies. Each shower/bathtub included non-slip grip materials and handrails. The facility dining, living rooms and den all included adequate seating, lighting and activity materials for residents in care. Hallway closets held extra linens, towels, hygiene supplies.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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: 12/07/2023
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Food Service: Located in the rear of the facility, LPA observed adequate amounts of non perishable food and supplies for the number of residents in care. The facility also maintains three, (3) refrigerators to main the facility's food supplies. Sufficient amounts of food and beverages were observed inside as well. The kitchen contained properly storage for its utensils, cups, dishware and pots and pans. Chemicals and sharp objects are kept secure under the kitchen sink inaccessible to residents in care. Emergency water supplies are also kept in the rear of the facility.

Care & Supervision: Facility maintains sufficient care staff; who assist residents 24 hours and 7 days a week. LPA reviewed staff files and found that all staff files included verifications for: Criminal Background Check, Fingerprint Clearances, Health Screenings, and training for: CPR/1st Aid, Medication Management, Mandated Reporting, HIPPA, Documentation and preventing behaviors.

Record Review and Resident/Staff Files: LPA observed that resident records are complete with Physician Reports and Needs and Services Plans, Admissions Agreements, Individualized Program Plans. Out of 15 resident files, 2 residents did not have updated Physician’s Reports.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, Personal Rights and facility license are posted in the hallway of the facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored in a secure cabinets; which is also where the first aid kit and additional supplies can be found. LPA reviewed residents' medication lists. Centrally Stored Medication Log. LPA Coleman did not observe any medication abnormalities.

No deficiencies were cited during this inspection. Exit interview conducted and copy of this report was provided to Administrator/Licensee Elia Marlia.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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