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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604023
Report Date: 02/24/2023
Date Signed: 02/24/2023 06:49:31 PM

Document Has Been Signed on 02/24/2023 06:49 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BRANDYWOOD HOME 2FACILITY NUMBER:
374604023
ADMINISTRATOR:GUITIERREZ, KINNAHFACILITY TYPE:
735
ADDRESS:4944 CLEARVIEW WAYTELEPHONE:
(619) 263-7444
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 4CENSUS: 4DATE:
02/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Caregiver Edna Francia & Assistant Administrator Celia GutierrezTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Caregiver Edna Francia. LPA then met and discussed the purpose of the visit with Assistant Administrator Celia Gutierrez.

Today's visit was in response to a self-reported AWOL (absent without leave) event involving Client #1 (C1) received in the San Diego Regional Office on 02/23/2023 [see LIC 811 Confidential Names List for a description of C1]. Per the LIC624 Incident Report which licensee submitted to CCLD, C1 was located within an hour, and was returned to the facility unharmed.

LPA performed facility tour / welfare check, collected records, and interviewed C1 and staff. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Gutierrez, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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