374604637-3-6-2023-08-AS-DNGN-CPP2DT-20230306161851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604637
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:18:56 PM

Document Has Been Signed on 03/06/2023 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	BRAMBLEWOOD ARF		FACILITY NUMBER:	374604637
ADMINISTRATOR:	NOVAK, PARLAR		FACILITY TYPE:	735
ADDRESS:	1261 PERSHING ROAD		TELEPHONE:	(619) 392-5802
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY: 6		CENSUS: 0	DATE:	03/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Applicants Parlar Novak and Alejandra Basurto		TIME COMPLETED:	04:20 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 (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to applicants Parlar Novak and Alejandra Basurto.

The facility fire clearance was granted on January 18, 2023 and reflects that the facility is approved for six (6) ambulatory clients.

During today’s visit, LPA, accompanied by the applicants, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 72 F. Water temperature at taps available to clients were compliant: Kitchen was 118.4 F, Bathroom #1 was 111.7 F, Bathroom #2 was 108 F, and Bathroom #3 was 106 F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future client use. Refrigerator temperature was 40 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and client activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the applicant, no firearms or ammunition are or will be stored at the facility.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BRAMBLEWOOD ARF	FACILITY NUMBER: 374604637
	VISIT DATE: 03/06/2023

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
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Three (3) fire extinguishers and two (2) first aid kits were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The applicants passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit.

Novak and Basurto were advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicants, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2