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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801899
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:26:58 PM


Document Has Been Signed on 12/08/2022 12:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BRIO MANORFACILITY NUMBER:
565801899
ADMINISTRATOR:JOHNEIL BRIONESFACILITY TYPE:
740
ADDRESS:115 THAMES STREETTELEPHONE:
(805) 379-9698
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Violeta Araos / Johneil BrionesTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control. The last annual conducted at this facility was on 11/07/2019. Upon arrival, LPA was scanned and greeted at the door by House Manager, Violeta Araos. The Licensee, Johneil Briones arrived shortly after and the reason for the visit was explained. Entrance interview.

At 10:20 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps locked in a drawer inaccessible to residents. Cleaning supplies and toxins were observed locked under the kitchen sink.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: There are two (2) resident restrooms, one in the hallway and another in the master bedroom. Both restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Restrooms were measured for hot water; the first bathroom measured at 129.2 degrees Fahrenheit at 10:25 a.m., and the second bathroom measured at 134.6 degrees Fahrenheit at 10:27 a.m. The Administrator adjusted the water temperature at the time of visit.

…Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BRIO MANOR
FACILITY NUMBER: 565801899
VISIT DATE: 12/08/2022
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…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. There is another refrigerator in the garage with additional food. The LPA observed a sufficient supply of emergency water and food. Two (2) fire extinguishers were observed to be fully charged on 2/02/2022. The facility maintains at a temperature of 74 degrees. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. The LPA observed the pool unlocked at 10:34 a.m. accessible to residents in care. The staff immediately locked the pool with a combination lock at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed two (2) residents in the living room watching television at the time of visit. Medication was observed in a locked closet adjacent to the living room.


INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The appropriate hand-washing signs were observed throughout. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. Staff were observed wearing face masks during time of the visit. No identified staffing concerns.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Civil Penalties assessed today in the amount of $500. Appeal Rights Discussed. A copy of the report was provided to the Licensee via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/08/2022 12:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BRIO MANOR
FACILITY NUMBER: 565801899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as two (2) out of two (2) facility restroom faucets delivers hot water measured at 129.2 and 133.6 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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Plan of Correction met. The Administrator adjusted the thermostat during time of visit.
Type A
Section Cited
CCR
87705(e)
87705(e) Care of Persons with Dementia. (e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as the gate leading to the swimming pool was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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Plan of Correction met. The Administrator ensured that the gate was locked and inaccessible to residents in care.

Zero Tolerance violation; a civil penalty was assessed during today's visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3