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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200070
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:46:48 PM

Document Has Been Signed on 08/13/2024 02:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BRIDGE PROGRAM - PLEASANT HILLFACILITY NUMBER:
079200070
ADMINISTRATOR/
DIRECTOR:		CARSWELL, JOHNFACILITY TYPE:
735
ADDRESS:550 PATTERSON BLVD.TELEPHONE:
(925) 938-8050
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 64CENSUS: 59DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:John Carswell, Campus Administrator
TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 08/13/2024 at 10:30am Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 07/15/2024. LPA met with Campus Administrator
John Carswell and explained the purpose of the visit.

On 07/15/2024 LPA L. Alexander received an email from S1 informing that R1 was involved in a serious accident on the freeway. S1 stated that R1 was struck by traffic and sustained significant injuries as a result. S1 stated that emergency services responded promptly on location of accident and transported R1 to John Muir Trauma Center in Walnut Creek for immediate medical attention.

On 07/29/2024 LPA L. Alexander received an email from S2 informing that R1 passed away on 07/28/2024 after being removed from his ventilator.

On 08/13/2024 LPA L. Alexander interviewed S2 and S3. S2 stated that on 07/14/2024 they were working on-call duty and received a call from the floor staff. S2 stated that staff informed that R1 was struck by a car and was at John Muir. S2 stated that the details were limited from John Muir Trauma Center. S2 stated that what they know is that R1 was walking and the accident was on N. Main Street and Interstate 680 Hwy during the late afternoon. S2 stated that they contacted local law enforcement agencies, which included Pleasant Hill Police Department (PD), Walnut Creek PD and California Highway Patrol (CHP) and was told that there were no pedestrian accident reported.

LIC809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 08/13/2024
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LPA obtained the following documents: Admission Record Face Sheet, Admission Agreement, Physician's Report, Initial Assessment, Primary Assessment, Psychiatric Services Progress Note, Crestwood Hospitals Transfer/Discharge Form, After-Visit Summary (10/09/23), Service Plans, Medication Administration Record (MAR) for May-July 2024, and Centrally Stored Medication and Destruction Record (CSMDR) for May-July 2024.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2024 02:46 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 08/13/2024 at 01:40 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
85068.4(d)(e)(f)

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(d) The licensee shall ensure...Needs and Services Plan...60 years of age...updated...in accordance with Section 85068.3. (e)The licensee shall ensure that the medical assessment...60 years of age...in accordance with the regulations...Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)]. (f)The Department may require the licensee to comply...protect the health and safety of clients 60 years of age or older...

This requirement is not met as evidenced by:
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Administrator agree to write a detailed plan that includes in-training with staff on policy and procedures for addressing clients annual medical assessments and annual appraisals to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in by not having updated and annual medical assessments and Needs and Services Plans not including all updated clinical assessments for R1 which poses an immediate 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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