191202023-5-6-2025-34-CR-DCMN-DGDV8C-20250505161230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191202023
Report Date: 05/05/2025
Date Signed: 05/06/2025 08:27:44 AM

Document Has Been Signed on 05/06/2025 08:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CRP RO, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

FACILITY NAME:	RANCHO SAN ANTONIO - BROTHER JOHN'S HOUSE		FACILITY NUMBER:	191202023
ADMINISTRATOR/ DIRECTOR:	BRIAN YABU		FACILITY TYPE:	733
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 16	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	05/05/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Troy McNair-Residential Director		TIME VISIT/ INSPECTION COMPLETED:	04:15 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 May 5, 2025 at 10:00am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting an Annual/Random inspection. LPA met with Troy McNair and together, conducted an inspection of the The Brother John's House. The Brother John's House consists of one building with two sides: Frisco/Rafael & Flippo/Fernando. There are 4 hallways in total. 4 beds in each hallway with a total of 16 beds. The Brother John's House services 12-17 Minors and Non-Minor Dependents. The Inspection went as follows: Frisco: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Rafael: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Flippo: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Fernando: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Cont. 9099-C

JoAunne Griffin	TELEPHONE: (310) 916-8782
Donald C Martin	TELEPHONE: (424) 301-3026
	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

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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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)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CRP RO, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

FACILITY NAME: RANCHO SAN ANTONIO - BROTHER JOHN'S HOUSE	FACILITY NUMBER: 191202023
	VISIT DATE: 05/05/2025

NARRATIVE

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The common area in Frisco/Rafael and Flippo/Fernanado contain a sectional, two large book cases, a TV on the wall and a computer desk area. There are 2 Therapists offices against the wall. The kitchen area has a sink, microwave and a room with a refrigerator in it. This area is for clients snacks and to heat up leftover food. Note: clients eat their meals in the cafeteria. No foods are prepared in the unit kitchens. The facility uses a cleaning service for the linen. The supply is kept in another building. Staff has access to them at anytime of the day and night.

Dividing the hallways is a desk where staff sits. Behind that desk is a staff office where supplies for cleaning and snacks are kept locked up as well.

The bathrooms contains 4 sinks, four urinals, four stalls that contain toilets, a water faucet and a large shower area with 4 shower head areas with dividers. Behind the bathroom area is the Laundry Room. The laundry room has two large machines for the clients clothing and towels.

The overall facility was in good condition, Note: LPA discussed the importance of unit cleanliness with Residential Director, Troy McNair. Both facility units, rooms and common areas were in disarray. Facility needs to come up with a plan to endorse unit cleanliness. It can be incentive based as well. Staff needs to understand that if they are unable to get the clients in care to keep the unit clean, it becomes their responsibility. Most of the clients were in school at the time of the visit. The unit should at least be clean when the unit is empty.

Staff and Clients were interviewed. Client and staff files are on the computer system and up to date.

There were no citations given at the time of the inspection.

SUPERVISOR'S NAME: JoAunne Griffin	TELEPHONE: (310) 916-8782
LICENSING EVALUATOR NAME: Donald C Martin	TELEPHONE: (424) 301-3026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

LIC809 (FAS) - (06/04)

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