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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191641459
Report Date: 11/09/2021
Date Signed: 11/09/2021 04:15:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:BRAVO FAMILY HOME INC.FACILITY NUMBER:
191641459
ADMINISTRATOR:IRMA BRAVOFACILITY TYPE:
740
ADDRESS:236 4TH AVE.TELEPHONE:
(310) 458-8006
CITY:VENICESTATE: CAZIP CODE:
90291
CAPACITY:6CENSUS: 2DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Ivan Bravo-AdminstratorsTIME COMPLETED:
04:15 PM
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On 11/9/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ivan Bravo and explained the purpose of today’s visit. The facility is an RCFE licensed for six (6) non- ambulatory client. Currently, there are (2) two non-ambulatory residents residing in the facility, all 60 or older.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: (4) resident bedrooms, (2) resident bathrooms, (1) staff bedroom, (1) staff bathroom, living room, dining room, kitchen, detached garage/ storage/ laundry room, porch with patio cover and seating area with dining table. Kitchen was inspected and observed to be clean and operational. A 2-day supply of perishable and 7-day supply of non-perishable food are present in the facility.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies and toxins, were stored in the laundry room and sharps objects are stored in locked kitchen drawers, locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two fully charged fire extinguishers were kitchen and backyard.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, All mandated inspection control posters were posted.

No deficiencies were cited during visit.

Advisories are on attached 9102

An exit interview was conducted, and a copy of this report was provided to Ivan Bravo, Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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