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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005815
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:18:50 PM

Document Has Been Signed on 11/03/2021 02:18 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BROOKLYN HOME CAREFACILITY NUMBER:
306005815
ADMINISTRATOR:CRUZ, CHONA M.FACILITY TYPE:
740
ADDRESS:902 BROOKLYN AVENUETELEPHONE:
(714) 203-1366
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 4DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Chona CruzTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA signed in and completed a temperature check. LPA met with Administrator, Chona Cruz, informed AD of the purpose of the visit, and conducted a tour of the inside and outside of the facility, common areas, kitchen, bedrooms, bathrooms, and garage.

LPA discussed and observed the following:

LPA observed Covid-19 station with sign in sheet, hand sanitizer, and disinfectant wipes. The facility also requires temperature checks for all visitors and staff. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed 30-day PPE supply. Hallways and walkways were free from obstruction. LPA reviewed Covid-19 Mitigation Plan and reviewed Covid-19 temperature log for residents. LPA provided technical assistance on checking and documenting temperature for staff members. LPA provided technical assistance regarding Covid-19 related training and documentation. LPA discussed updated Covid-19 requirements including surveillance testing, signage, and Covid-19 reporting requirements.

No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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