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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700564
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:56:41 PM


Document Has Been Signed on 04/18/2023 04:56 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: DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Katrina and PenafranciTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with Katrina and Penafranci explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.9 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers is outdated there is no service date on the extinguisher. Smoke detectors and carbon monoxide detector is current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident and 2 staff files, including criminal record clearances. All staff are fingerprint cleared and is associated to the facility. First aid kit was checked and is complete.

No deficiencies were cited per Title 22 Regulations and the Health and Safety Code. Appeal Rights provided, exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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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