366401612-10-3-2025-56-AS-LFAW-DM4SYG-20251003141731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366401612
Report Date: 10/03/2025
Date Signed: 10/03/2025 02:17:45 PM

Document Has Been Signed on 10/03/2025 02:17 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BROTHERS HOME HEALTH CARE, INC.		FACILITY NUMBER:	366401612
ADMINISTRATOR/ DIRECTOR:	MARLIA, DOMINIC J.		FACILITY TYPE:	735
ADDRESS:	240 W. HAWTHORNE STREET		TELEPHONE:	(909) 586-5797
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 6		CENSUS: 4	DATE:	10/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:33 AM
MET WITH:	Elia Marlia, Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Brother's Home Health Care, Inc. Adult Residential Facility to conduct the Annual Inspection. LPA rang door bell and knock on the door and was greeted and invited inside the facility by Caregiver, Toni Fnu. LPA introduced self and stated the purpose of the visit, then provided a space to work. LPA met with Licensee, Elia Marlia and was accompanied by Licensee on a tour of the facility, inside and outside, and observed the following: Facility: The facility, is approved for a capacity of 6 residents, current census is four (4). All four (4) resident are away at the day program. Two, (2) of 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 at 71 degrees. 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 February 14, 2025. Administrator reports that the facility conducts fire drills every month or nothing less than every quarter. Last fire/disaster drill conducted July 2025. 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 water temperature measures at 102.6, 103.7 and 102 which below regulation. A technical advisory issued. The facility have a separate staff bathroom. 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.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 10/03/2025 02:17 PM - It Cannot Be Edited

Created By: Lavette Farlow On 10/03/2025 at 01:15 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROTHERS HOME HEALTH CARE, INC.	FACILITY NUMBER: 366401612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring the facility had an Infection Control Plan development for the staff and CCL review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2025
	Plan of Correction
1 2 3 4	The Licensee agree to develop an Infection Control Plan and update and maintain the plan according to regulation. Licensee agree to conduct an annual training regarding Infection control or as need for staff. Licensee will provide the Infection control plan to LPA and a statement of understanding by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:

	Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROTHERS HOME HEALTH CARE, INC.	FACILITY NUMBER: 366401612
	VISIT DATE: 10/03/2025

NARRATIVE

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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 maintain 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.

Record Review and Resident/Staff Files: LPA reviewed administrator and two (2) Care Provider files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. P & I funds were counted at random and matched with the ledger. LPA observed 1 out of 2 clients had an incomplete admission agreement. A technical violation was issued. 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. Centrally Stored Medication Log. LPA Farlow did not observe any medication abnormalities. Medication was audited and matched with MARS. LPA reviewed facility's file for fire drills, infection control plan, and emergency disaster plan. LPA observed that the facility did not have a infection control plan available for review. A deficiency was cited.
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.

One deficiencies was cited during this inspection. One technical violation, one technical advisory. A exit interview was conducted and a copy of this report LIC809, LIC809C, LIC809D LIC9102TA and LIC9102TV was provided to Administrator/Licensee Elia Marlia, and Administrator Abraham Esquivel.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025

LIC809 (FAS) - (06/04)

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