565801899-12-4-2023-29-AS-ECAS-CY7VTS-20231204154337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801899
Report Date: 12/04/2023
Date Signed: 12/04/2023 03:44:26 PM

Document Has Been Signed on 12/04/2023 03:44 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 MANOR		FACILITY NUMBER:	565801899
ADMINISTRATOR:	JOHNEIL BRIONES		FACILITY TYPE:	740
ADDRESS:	115 THAMES STREET		TELEPHONE:	(805) 379-9698
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Johneil Briones		TIME COMPLETED:	03:50 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) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Johneil Briones arrived shortly thereafter.

The LPA and Staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA toured the kitchen/food service area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature was measured in the kitchen and measured 120.2 degrees Fahrenheit.

BEDROOMS/BATHROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 1:42 p.m. the LPA observed accessible scissors in bedroom #3 in a drawer next to the resident’s bed. The scissors were taken out and locked with the sharps immediately upon discovery. There are five designated resident rooms and one staff room. The two resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured at 120.1 degrees Fahrenheit in the hallway bathroom.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 73 degrees F. Smoke detector(s) and carbon monoxide detector were tested at 1:32 p.m. and operational at the time of the visit. The two fire extinguishers were fully charged and last purchased on 12/4/23. The LPA observed required postings throughout the common space. There is a laundry room located in the main hallway and all cleaning and laundry supplies are kept locked and inaccessible. ** Continued on LIC 809-C**

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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 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: 12/04/2023

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

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for resident exit and is single latched, all exits are free of obstructions. There is a gated pool which was locked and inaccessible at the time of the visit. There is an attached garage with an additional refrigerator with perishable and non-perishable food items. At 11:25 a.m. the LPA observed various expired dry food items such as macaroni and cheese, crackers, cereal and dry pasta. All identified items were discarded immediately. Additionally, two cartons of eggs requiring refrigeration were located outside of refrigerator and both cartons were discarded immediately. Cleaning supplies and tools are kept locked in the garage. The LPA observed an adequate supply of emergency food and water including a sufficient supply of Personal Protective Equipment (PPE). In addition the LPA observed the required generator with a generator switch in the backyard area.

Due to time constraints, the LPA will return at a later date to complete the inspection.

The LPA obtained the following documents:

- Resident Roster
- Liability Insurance

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/04/2023 03:44 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: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the LPA observed expired dry food items in the garage along with cartons of eggs that were not refrigerated which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	Licensee agreed to the following: 1. Dispose of expired food items. POC met at time of the visit.

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as a pair of scissors were observed accessible in the drawer next to the bed in bedroom # 3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	Licensee agreed to the following: 1. Remove all lock scissors with other sharps. POC met at time of the 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3