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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700564
Report Date: 07/26/2022
Date Signed: 07/26/2022 03:40:25 PM

Document Has Been Signed on 07/26/2022 03:40 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:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:PenafranciTIME COMPLETED:
12:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a Case management. LPA met with Penafranci explained the purpose of the visit.

LPA was following up on the request for an exception for R1. R1 graduated from hospice on 3/13/2022. During this visit LPA was made aware that R1 is now back on hospice and there is no need to have home health or an exception to keep R1 in her current setting.

During the safety check LPA observed an outdated Fire extinguishers. LPA reviewed and compared resident medication vs. resident medication logs for R1.

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: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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 07/26/2022 03:40 PM - It Cannot Be Edited


Created By: Albert Johnson On 07/26/2022 at 12:15 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: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2022
Section Cited
CCR
87202

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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The Licensee agrees to purchase a new fire extinguisher or service the current fire extinguishers. The Licensee will send a copy of the purchase receipt or a picture of new service tag for the fire extinguishers by POC date via email to CCL.
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Fire extinguisher was observed by House manager and LPA to have tagged dates of 05/24/2021.
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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: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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