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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602872
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:15:19 PM

Document Has Been Signed on 10/26/2023 04:15 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BRISA DEL SOLFACILITY NUMBER:
374602872
ADMINISTRATOR:SALVADOR ANTONFACILITY TYPE:
735
ADDRESS:38133 HIGHWAY 94TELEPHONE:
(619) 746-4664
CITY:BOULEVARDSTATE: CAZIP CODE:
91905
CAPACITY: 4CENSUS: 4DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caregiver Alexandra Calderon and Driver Jesus CalderonTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Alexandra Calderon. The facility was licensed for a capacity of four (4) clients. At the time of the visit the facility had four (4) clients in care.

The LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas.



No pools or bodies of water on the premises. Per staff, no firearms or ammunition were kept at the facility. Carbon monoxide detectors, and Fire extinguisher were present.

The LPA conducted interviews of staff and client and reviewed staff and client records. Staff records were not present at the time of the visit. This deficiency was cited in an LIC 809D and a Plan of Correction was jointly formulated with Caregiver Alexandra Calderon.

An exit interview was conducted with Calderon, to whom a copy of this report, LIC 809D and the Licensee/Appeal Rights (LIC9058 03/22), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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Document Has Been Signed on 10/26/2023 04:15 PM - It Cannot Be Edited


Created By: Sabel Martinez On 10/26/2023 at 03:43 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BRISA DEL SOL
FACILITY NUMBER: 374602872

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to 4 of 4 persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Caregiver agreed to submit staff records to the Department, by 11/24/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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