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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700564
Report Date: 04/19/2022
Date Signed: 04/29/2022 10:21:34 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/29/2022 10:21 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BRIONES FAMILY HOMECAREFACILITY NUMBER:
392700564
ADMINISTRATOR:BRIONES, ERWINFACILITY TYPE:
740
ADDRESS:3205 ESTRELLA AVETELEPHONE:
(650) 238-8347
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jean BrionesTIME COMPLETED:
04:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with Penafranci explained the purpose of the visit. Later joined by Jean Briones

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.9 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers, smoke detectors and carbon monoxide detector are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs.

During the file review it was discovered that R1 does not have a package for home health services, including: Foley catheter maintenance (last records indicated that the catheter was changed on 3/16/2022), medications management and positioning
(currently facility staff are turning R1 every two hours). R1 graduated from Hospice on 3/13/2022(?) no records to support this date. LPA reviewed 4 resident and 2 staff files, including criminal record clearances.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BRIONES FAMILY HOMECARE
FACILITY NUMBER: 392700564
VISIT DATE: 04/19/2022
NARRATIVE
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 All staff are fingerprint cleared and is associated to the facility. During the staff file review, S1 did not have a health screening or TB test completed. First aid kit was checked and is complete. Fire drill has not been completed.

The following deficiencies were cited on 809- D attached as per Title 22 Regulations and the Health and Safety Code. Appeal Rights provided, exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/29/2022 10:21 AM - It Cannot Be Edited


Created By: Albert Johnson On 04/19/2022 at 03:05 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BRIONES FAMILY HOMECARE
FACILITY NUMBER: 392700564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2022
Section Cited
CCR
87411(f)

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General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment.
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Administrator to provide a health screening/TB results for staff (S1) by POC date 4/20/2022
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LPA observed staff did not have a health screening and TB test results in S1's file.
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Type A
04/20/2022
Section Cited
CCR87612(a)(2,4,7,)

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87612 Restricted Health Conditions (a)The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services:
(2) Catheter care as specified in Section 87623.
(4) Contractures as specified in Section 87626.
(7) Incontinence of bowel and/or bladder as specified in Section 87625.
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Administrator will provide the department with an order from the Primary care physician of R1 to confirm discharging from Hospice and starting home health services.
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This requirement is not met as evidenced by records review the facility does not have records of home health services to address the needs of R1. This poses an immediate risk to residents in care.
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This information shall be submitted by POC date 4/20/2022.

The facility will also request an exemption for R1 by POC date 4/20/2022
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


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Document Has Been Signed on 04/29/2022 10:21 AM - It Cannot Be Edited


Created By: Albert Johnson On 04/19/2022 at 03:53 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BRIONES FAMILY HOMECARE
FACILITY NUMBER: 392700564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited
HSC
1569.695(c)

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Drills shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
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Administrator agreed to conduct a fire drill and submit proof to CCLD by POC date.
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Based on observation the licensee did not comply with the section cited above in 1569.65(c). LPA observed Administrator was unable to provide a copy of facility fire drill, which poses/posed a potential health, safety or personal rights risk to persons 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


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