191641459-11-14-2024-11-AS-SDAY-DAZQUJ-20241114112848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191641459
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:28:54 AM

Document Has Been Signed on 11/14/2024 11:28 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	BRAVO FAMILY HOME INC.		FACILITY NUMBER:	191641459
ADMINISTRATOR/ DIRECTOR:	IRMA BRAVO		FACILITY TYPE:	740
ADDRESS:	236 4TH AVE.		TELEPHONE:	(310) 458-8006
CITY:	VENICE	STATE: CA	ZIP CODE:	90291
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Ivan Bravo, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Ivan Bravo, Administrator, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents residents. Currently there is 2 residents in placement here. There is a dementia waiver on file. (1) resident is diagnosed with dementia. No residents are receiving home health or hospice care services. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (4) resident bedrooms, (2) resident bathrooms, 1staff bedroom, 1 staff bathroom, living room, kitchen with dining area, detached garage where the laundry room is located and an outdoor shaded patio area.

LPA and Administrator Ivan Bravo toured the facility. All resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 111.F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During todays visit LPA observed the following deficiencies:

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Janae Hammond	TELEPHONE: (424) 544-1027
Sparkle Day	TELEPHONE: (424) 544-1075
	DATE: 11/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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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Document Has Been Signed on 11/14/2024 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRAVO FAMILY HOME INC.	FACILITY NUMBER: 191641459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, interview with Administrator and facilty record review, the licensee did not comply with the section cited above in [3] out of [3] persons did not have a current First Aid certificate on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	Administrators agrees to have a First Aid training by POC date. Administrator will email copies of certificates to LPA: Sparkle.day@dss.ca.gov

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill 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:
	Deficient Practice Statement
1 2 3 4	Based on LPAs interview with Administrator Ivan Bravo and facility record review, the licensee did not comply with the section cited above . Administrator only conducts fire drills (1) time a year for the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	Administrator agrees to conduct fire drill quarterly starting with the first drill being by or before the POC date. Administrator will send LPA a copy of the fire drill report to : Sparkle.day@dss.ca.gov by POC date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Janae Hammond	TELEPHONE: (424) 544-1027
Sparkle Day	TELEPHONE: (424) 544-1075
	DATE: 11/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRAVO FAMILY HOME INC.	FACILITY NUMBER: 191641459
	VISIT DATE: 11/14/2024

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Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies:

On 11/14/24 LPA reviewed Staff #1, Staff #2 and Staff #3 files. LPA observed that Staff #1 - Staff #3 did not have a current First Aide certificate on file

- On 11/14/24 LPA reviewed Facility files and observed and was confirmed by Administrator Ivan Bravo that fire drills are only conducted once and year.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator . A copy of this report and appeal rights were discussed and left wit Administrator, Ivan Bravo.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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