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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920080
Report Date: 12/10/2024
Date Signed: 12/10/2024 10:24:06 AM

Document Has Been Signed on 12/10/2024 10:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MY BROTHER'S HOUSEFACILITY NUMBER:
345920080
ADMINISTRATOR/
DIRECTOR:
POSADAS-WORSFORD, ELOISA MFACILITY TYPE:
740
ADDRESS:8501 OAKCREEK COVE WAYTELEPHONE:
(916) 548-4409
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 5DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Licensee, Mary Maybel Mata TIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 12/10/24 to conduct the annual inspection. LPA met with Licensee, Mary Maybel Mata (Mary ) and explained the purpose of the visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). All resident files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. All required posting were observed. Staff training contained the required initial training and annual training. LPA reviewed medications of two (2) residents comparing with physician orders and find no errors.

LPA and Mary toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 12/31/24.

No deficiency cited during today's visit. Exit interview conducted .
A copy of this report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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