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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201387
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:54:11 PM

Document Has Been Signed on 10/23/2024 03:54 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:BR CAREFACILITY NUMBER:
079201387
ADMINISTRATOR/
DIRECTOR:		BERNARDINO-RUIZ, JAMIEFACILITY TYPE:
740
ADDRESS:2830 HAWTHORN CTTELEPHONE:
(925) 698-1207
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 2DATE:
10/23/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Mark Ruiz, Administrator &
Jamie Ruiz, Administrator		TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On 10/23/2024 1:50PM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced Post Licensing inspection and met with Administrators (ADMs). LPA explained the purpose of the visit with ADMs. Administrator 1, holds a current certificate (#7035384740), which expires on 10/04/2025. Administrator 2, holds a current certificate (#6037285740), which expires on 10/04/2025. LPA observed one male resident with his wife in the living room watching TV and another male in his room watching TV.

At 2:10PM, LPA inspected including, but not limited to, living room, kitchen, dining area, bathrooms, bedrooms, laundry area, activity room and outside areas. There were no bodies of water present at the facility. The facility has ten (10) bedrooms and four (4) bathrooms. Three bedrooms and one bathroom is designated for staff use only. Ample supply of toiletries and linens are available. Sufficient lighting and furniture throughout facility. 2 day perishable and 7 day non perishable food supply are available. Facility's inside temperature is maintained at 72 degrees, F.

At 2:26PM, LPA observed Hot water temperature in resident's bathroom was measured at 111.7 degrees, F. Medications, toxins and sharps observed stored locked and inaccessible to residents in care. Fire extinguisher, smoke and carbon monoxide detectors were observed operational. Emergency Disaster Plan dated 09/25/2024 was near required posters and were centrally posted. Exits and passageways are free of obstruction. Disaster drills are conducted every three months.

Continued on next page, LIC809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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: BR CARE
FACILITY NUMBER: 079201387
VISIT DATE: 10/23/2024
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Continue from LIC809

At 2:41 PM LPA reviewed two (2) residents and four (4) staff files, medication and medication logs. Staff were fingerprint cleared and associated to facility. Resident file contain Admission agreement, Pre-placement appraisal, ID/Emergency information, Personal Rights, Physician's report, Safeguard of property & valuables.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/25/2024:

· LIC 500- Personnel Report
· LIC 308- Designation of Facility Responsibility
· LIC 610E- Emergency/Disaster Plan (9 pages)
· Evidence of Liability Insurance

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided to Jamie Ruiz.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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