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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002155
Report Date: 07/13/2023
Date Signed: 07/13/2023 11:12:22 AM

Document Has Been Signed on 07/13/2023 11:12 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BRANDON MANORFACILITY NUMBER:
306002155
ADMINISTRATOR:MARY YEPESFACILITY TYPE:
740
ADDRESS:28421 BRANDON DR.TELEPHONE:
(949) 365-9082
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 5CENSUS: 5DATE:
07/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Mary YepesTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. This visit is to address issues observed during the complaint visit that are not related to the complaint. LPA met with the facility Administrator and explained the reason for the visit. During the complaint investigation visit (complaint # 22-AS-20230707083239) it was observed that the master bedroom closet has a bed and unsecured medications stored next to the bed in a box. The master bedroom is a shared room and is occupied by two residents. LPA observed the closet does not have a lock on the door or any means to secure it. The Administrator reported that the medications need to be destroyed since they have been discontinued. The Administrator reported that some of the medications are prescribed for their use. LPA observed the medications were for the Administrator and some of the residents. The Administrator reported that they use the closet as a break room. The Administrator reported that the items in the closet belong to her and some of the residents. LPA observed the mail on the bed was all addressed to the Administrator. LPA informed the Administrator that the bed must be removed and the medications secured and then disposed of properly. The Administrator stated she understood.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6, Chapter 8 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was provided to the Facility Administrator.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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Document Has Been Signed on 07/13/2023 11:12 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/13/2023 at 10:42 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BRANDON MANOR
FACILITY NUMBER: 306002155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2023
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not being met as evidenced by,
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Licensee agrees to store all medications in compliance with CCR 87465. Licensee agrees to dispose of discontinued medications in compliance with Title 22. Licensee will conduct training with all staff regarding CCR 87465 and to provide proof of training to LPA by POC due date.
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LPA observed medications for residents stored in the master bedroom closet unsecured. This poses an immediate health and safety risk to residents in care.
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Type B
07/20/2023
Section Cited
CCR87307(a)(2)(B)

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No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not being met as evidenced by,
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Licensee agrees to move the bed and all items not belonging to the residents out of the master bedroom closet. Licensee agrees not to use any room, other than it's commonly used purpose as stated in CCR 87307.
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LPA observed the master bedroom closet has a bed and is being used as a bedroom. This poses a potential health and safety risk to residents in care.
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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:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023


LIC809 (FAS) - (06/04)
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