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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002155
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:03:31 PM

Document Has Been Signed on 03/19/2024 02:03 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
ORANGE COUNTY RO, 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: 3DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Mary YepesTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Staff 3. There were no other staff members at the facility when the LPA arrived. LPA explained the reason for the visit. LPA and staff toured the facility. The Administrator Mary Yepes arrived at 11:30am. The Administrator's Certificate expired on December 29, 2023. The Administrator reported they sent in all the required documents verifying continued education and payment on March, 15, 2024. LPA observed the PUB 475 poster posted in the living room. The facility is a single story home with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, family room with a screened fireplace, laundry room and an attached two care garage. The garage is used for storage and kept locked. LPA observed all resident rooms had the required furniture. All of the resident rooms are clean and organized. How water measured 109.2 degrees Fahrenheit in both bathrooms. LPA observed the kitchen is clean and organized. Knives and sharp objects are kept locked under the kitchen sink. The fire extinguisher in the kitchen is fully charged. Medications are kept locked in a kitchen cabinet. LPA and Administrator toured the backyard. There are table and chairs in the backyard for sitting outside. The patio is covered and there is a small gazebo. LPA observed a small raised fountain. Both exit gates are operational. Smoke detectors and carbon monoxide detectors tested operational. LPA inspected the First-Aid kit, it has all the required elements. LPA reviewed 3 out of 3 staff files. LPA observed Staff 3 had no training documented and no initial training documented. Staff 3 did not have CPR/First Aid training. LPA reviewed resident files. LPA observed Resident 3 did not have a signed admission agreement on file. LPA reviewed all 3 resident medications. No discrepancies observed.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6, of the California Code of Regulations. See LIC809Ds. An exit interview was conducted and a copy of this report and appeal rights was provided to the Facility Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 03/19/2024 02:03 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 03/19/2024 at 12:53 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BRANDON MANOR
FACILITY NUMBER: 306002155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in, when the LPA arrived at the facility the only staff present (Staff 3) did not have any CPR or First Aid training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Licensee agrees to Staff 3 trained in CPR and First-Aid. Licensee to forward proof of CPR and First-Aid training to LPA when completed.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/19/2024 02:03 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 03/19/2024 at 12:53 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BRANDON MANOR
FACILITY NUMBER: 306002155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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 1 out of 3 staff training files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to ensure all staff have the required training as stated in HSC 1569.69(a)(2) and to document all training completed by staff. Licensee to forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

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 1 out of 3 resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to have Resident 3's responsible party sign and date Resident 3's admission agreement. Licensee to submit proof to LPA by POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/19/2024 02:03 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 03/19/2024 at 01:26 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BRANDON MANOR
FACILITY NUMBER: 306002155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...

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. The Administrator's certificate expired on 12/29/2023. The facility has no currently certified administrator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Licensee agrees to forward proof to LPA that all required training has been completed, fees paid and all documents for renewal of the Administrator's Certificate have been submitted to Community Care Licensing Division Administrator Certification Bureau (ACB) by the POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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