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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700564
Report Date: 03/09/2023
Date Signed: 03/10/2023 01:28:09 PM


Document Has Been Signed on 03/10/2023 01:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:BRIONES FAMILY HOMECAREFACILITY NUMBER:
392700564
ADMINISTRATOR:BRIONES, ERWINFACILITY TYPE:
740
ADDRESS:3205 ESTRELLA AVETELEPHONE:
(650) 238-8347
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
03/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:PenafranciTIME COMPLETED:
02:45 PM
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit.

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited has been cleared.

Deficiency cited under Title 22 Regulations has been cleared. Licensee did complied with the terms of the Plan of Correction by POC due date.

Exit interview conducted

Section Cited: 87202Date Due: 07/26/2022
Plan of Correction:
The Licensee agrees to purchase a new fire extinguisher or service the current fire extinguishers. The Licensee will send a copy of the purchase receipt or a picture of new service tag for the fire extinguishers by POC date via email to CCL.		Corrections:
Cleared By Visit		Clearance Date:
03/09/2023
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023
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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