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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700564
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:47:43 PM

Document Has Been Signed on 04/29/2022 12:47 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, 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:
04/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jean BrionesTIME COMPLETED:
01:06 PM
NARRATIVE
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual inspection conducted on 4/19/2022.

Deficiencies 87411(f) have been cleared along with citation 1569.695 (c) cited under Title 22 Regulations and Health and Safety Code have been cleared. Licensee complied with the terms of the POC by POC due date. However, citation 87612 Restricted Health conditions has not been met.

The Facility will need to provided the department with an exception request by 4/30/2022. R1 is being provided with home health services after graduating from hospice on 3/3/2022. The home health services started on 3/13/2022, based on plan of care documents reviewed.

The following deficiency 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: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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 04/29/2022 12:47 PM - It Cannot Be Edited


Created By: Albert Johnson On 04/29/2022 at 12:30 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: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2022
Section Cited
CCR
87616(a)(b)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
(b) Written requests shall include, but are not limited to, the following:
(1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition.
(2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility.(3) Plan for minimizing the impact on other residents.
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Licensee agrees to submit a request for an exception to retain (R1) who has a prohibited health condition. Licensee shall review the regulation on prohibited health condition and submit a statement of understanding of this regulation.
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R1 is being provided with home health services after graduating from hospice on 3/3/2022.
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The plan should be submitted by POC date.

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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: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
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