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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604504
Report Date: 12/19/2022
Date Signed: 12/19/2022 04:18:30 PM


Document Has Been Signed on 12/19/2022 04:18 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:BRANDYWOOD HOME 4FACILITY NUMBER:
374604504
ADMINISTRATOR:GUTIERREZ, KINNAHFACILITY TYPE:
735
ADDRESS:646 CLAMATH STTELEPHONE:
(619) 316-9311
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 1DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator Kinnah Camille Amante-GutierrezTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Tammer de los Santos visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Caregiver Christian Trambulo to whom LPA disclosed the purpose of the visit. Administrator Kinnah Camille Amante-Gutierrez

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough / sneeze etiquette, symptom, and transmission awareness; face coverings worn by staff; hand sanitizer readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products and personal protective equipment.

Administrator previously provided a copy of the completed Infection Control Plan.

No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Kinnah Camille Amante-Gutierrez, and copies of this report and Licensee Rights (LIC 9058) were provided at the conclusion of the visit. Facility representative’s signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Tammer DeLosSantosTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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