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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200523
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:15:40 PM

Document Has Been Signed on 01/30/2024 12:15 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BRUIZ CAREHOMEFACILITY NUMBER:
079200523
ADMINISTRATOR:BERNARDINO-RUIZ, JAMIE AFACILITY TYPE:
740
ADDRESS:2353 DEMARTINI LANETELEPHONE:
(925) 634-8802
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH: Administrator, Jamie Bernardino-Ruiz TIME COMPLETED:
12:25 PM
NARRATIVE
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On 01/30/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Jamie Bernardino-Ruiz and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory.

LPA toured facility with Jamie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 107.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced 7/19/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/08/2023 . Emergency disaster plan updated 7/15/2023.

At 9:30 AM, LPA reviewed 5 residents records. At 10:04 AM, LPA reviewed 5 staff records 5 of 5 are associated to the facility. At 11:00 AM, LPA reviewed a sample of resident’s medications.


Continues to 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRUIZ CAREHOME
FACILITY NUMBER: 079200523
VISIT DATE: 01/30/2024
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The following Deficiencies were Observed during Visit
  • During File review LPA observed that R5's physician report states that they are bedridden and not on Hospice. Facility is not cleared for bedridden.


Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 02/13/2024:

LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Updated Facility Sketch
Updated Fire Clearance


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/30/2024 12:15 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/30/2024 at 12:03 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRUIZ CAREHOME
FACILITY NUMBER: 079200523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R5 being bedridden when the facility is not cleared for bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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By POC date Adminstrator agrees to obtain a new Fire Clearence and submit it to CCLD.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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