392700564-6-9-2025-27-AS-NWPN-DHGTF4-20250609144055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700564
Report Date: 06/09/2025
Date Signed: 06/09/2025 02:41:10 PM

Document Has Been Signed on 06/09/2025 02:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BRIONES FAMILY HOMECARE		FACILITY NUMBER:	392700564
ADMINISTRATOR/ DIRECTOR:	BRIONES, ERWIN		FACILITY TYPE:	740
ADDRESS:	3205 ESTRELLA AVE		TELEPHONE:	(209) 292-8622
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	06/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	Jean Cherryl Briones		TIME VISIT/ INSPECTION COMPLETED:	02:45 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	On 6/9/25 at 8:48am Licensing Program Analyst(LPA) Noel Wolf Petersen and Licensing Program Manager(LPM) Liza King arrived to the facility unannounced met the administrator Jean Cherryl Briones and conducted an annual inspection. Briones Family Homecare is a 6 person facility with a current census of 5. Approved to accommodate 6 non ambulatory persons of which 3 may be bedridden. Hospice waiver approved for 6. Physical plant was inspected including but not limited to the bedrooms, bathrooms, hallways, storage, exteriors and evacuation routes. The traffic areas are unobstructed. Required furniture is present, infection control encasements for the mattress is missing in 1 of 5 beds. The facility is sanitary, night lighting is absent in the bathrooms and hallways. Sharps and Medications are locked away, toxics were locked with the exception of some hand soap. No bodies of water were observed. resident use water temp was taken at 109*F, Fire extinguisher was checked on 10-7-24. Fire drills are conducted quarterly. Smoke and CO detectors are functional. Required posters for Client Rights were not present.Technical Advisories are issued for the Physical Plant (Personal rights poster, bed bug encasements, non-toxic soap, and night lights), while no resident is at risk for these issues currently, future nonambulatory clients and ambulatory clients may be. 2 Client interviews were conducted. 5 client files were reviewed. MAR's for the clients are incomplete, missing elements like reasons and effects for PRN medications. The 602's and Needs and Appraisals forms need to be updated on a yearly basis. Residents with restricted conditions are accepted and retained without applying for exceptions (catheter use, contractures, and total care). The Licensee did inquire about a exception for cathether use to her LPA in January 2025. Continued on C page

Liza King	TELEPHONE: (650) 676-0442
Noel Wolf Petersen	TELEPHONE: (916) 263-4700
	DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

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 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BRIONES FAMILY HOMECARE	FACILITY NUMBER: 392700564
	VISIT DATE: 06/09/2025

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

2 Staff interviews were conducted. 2 staff records were reviewed for finger printing, background check clearances, required training's, and for first aid. Records are present and up to date.

The administrator records were reviewed including a Plan of Op, Liability insurance, and Admission agreement. Guardian facility profile needs to be updated. Plan of Op was prepared by a consultant, Administrator should review it, Administrator is not reporting unusual incidents as outlined in the Plan of Op. Dues are up to date.

Citations were issued on following D-pages.

Exit interview was conducted, the report was read and given to the administrator. Appeal rights were provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Noel Wolf Petersen	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/09/2025 02:41 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 06/09/2025 at 01:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BRIONES FAMILY HOMECARE	FACILITY NUMBER: 392700564
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 client MARs which neglected to document the effect of the PRN on the residents response or the reason satisfying its "as needed" basis. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Complete PRN, send a copy to LPA.

Type A

Section Cited

CCR

87405(d)(2)

87405 (d) (2) Administrator Qualifications and Duties - The administration shall have the qualifications specified...ability to conform to the applicable laws, rules, and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by accepting and retaining residents with restricted contions (catheter, contractures, and total care) without applying for an exception, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Licensee will apply for exceptions, (catheter, contractures, and total care), by the POC Date, send to the LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (650) 676-0442

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 263-4700

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/09/2025 02:41 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 06/09/2025 at 01:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BRIONES FAMILY HOMECARE	FACILITY NUMBER: 392700564
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 resident LIC 602 forms which were not filled out on an annual basis as detailed in the Plan of Operation, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2025
	Plan of Correction
1 2 3 4	Submit a 602 for the residents, when they get those appointments, to the LPA.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 resident needs and appraisals (LIC 625) were not completed annually or as needed which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2025
	Plan of Correction
1 2 3 4	The licensee will send the LPA updated needs and services for the clients who havent had one in the last year.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (650) 676-0442

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 263-4700

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5