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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610087
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:23:38 PM

Document Has Been Signed on 03/08/2022 01:23 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CON CARINO BRAEBURNFACILITY NUMBER:
197610087
ADMINISTRATOR:MORALES, LINDAFACILITY TYPE:
740
ADDRESS:1744 BRAEBURN RDTELEPHONE:
(626) 485-7756
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Linda Morales, Licensee TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection control inspection to the facility. LPA met with Licensee Linda Morales and explained the reason for the visit.

A tour of the physical plant was conducted at 11:00am and the following was noted:

There is only one entrance being utilized at the facility, there are required posters posted at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, and masks are available. LPA was screened upon entry.

The facility had submitted and approved Mitigation Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area in the backyard. The facility has sufficient stock of PPE in the garage.

The facility has six (06) bedrooms and four (04) bathrooms currently occupying six (06) residents. All rooms are private rooms.

(continued on LIC 809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CON CARINO BRAEBURN
FACILITY NUMBER: 197610087
VISIT DATE: 03/08/2022
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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75 degrees. The smoke detectors were observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located throughout the facility.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is a body of water at the facility. The swimming pool is gated and locked. It is inaccessible to residents.

Laundry area is located inside a closet, laundry detergents, cleaning agents and other toxins are stored in a locked cabinet.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 106.2 degrees. There was enough clean linen available in stock in the cabinets.

Medications-LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There is one ( 01) complete first aid kit.

Exit interview conducted. A copy of this report was issued and signature obtained.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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