191641459-4-28-2023-11-AS-ASOO-CLSQN5-20221204111834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191641459
Report Date: 12/04/2022
Date Signed: 04/28/2023 09:20:41 AM

Document Has Been Signed on 04/28/2023 09:20 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BRAVO FAMILY HOME INC.		FACILITY NUMBER:	191641459
ADMINISTRATOR:	IRMA BRAVO		FACILITY TYPE:	740
ADDRESS:	236 4TH AVE.		TELEPHONE:	(310) 458-8006
CITY:	VENICE	STATE: CA	ZIP CODE:	90291
CAPACITY:	6	CENSUS:	DATE:	12/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Ivan Bravo , Administrator		TIME COMPLETED:	11:30 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met with Ivan Bravo, Administrator and the purpose of today’s visit was explained.

There are currently (2) residents in the facility. (2) residents are ambulatory, (0) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (4) bedrooms, (3) full bathrooms, living, room, dining, kitchen, shaded back yard, front yard, and laundry room inside the detached 1 car garage.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. Bedroom 4 is a staff bedroom. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. 3rd bathroom is a staff bathroom. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file was current and medications were not current (doses missed- 1 pkg (gabapentin 100mg zolpiem 5mg - 2days missed) 1 pkg- (Buspirone 5mg Dicyclomine 10mg - 1 day missed): 1 pkg - (Gabapentin 100mg dicyclomine 10mg Buspirone 5mg - 1 day missed). (1) Staff file was not current (CPR card expired 2018). Ample supply of perishable and nonperishable food, hot water temperature is (120) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguisher is fully charged. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRAVO FAMILY HOME INC.	FACILITY NUMBER: 191641459
	VISIT DATE: 12/04/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the back porch. LPA observed staff was not wearing masks. resident private rooms will be converted to isolation rooms (if needed) trash cans had no lids, no cart for PPE’s, mitigation plan posted and/or in folder, NO - Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPhone for residents to use, resident’s temperatures are not checked or logged. Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisories (TA) issued.

1. Staff must wear masks.

2. Need trash cans with lids in restrooms.

3. Need Cart with wheels for PPE's.

4. No Fit testing for staff, must be completed.

5. Residents temperatures must checked at least once a day.

An exit interview conducted with Ivan Bravo, Administrator and a hard copy of report provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022

LIC809 (FAS) - (06/04)

Page: 7 of 7

Document Has Been Signed on 04/28/2023 09:20 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRAVO FAMILY HOME INC.	FACILITY NUMBER: 191641459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87465(a)(4)The licensee shall assist residents with self-administered medications as needed. This was not met as evidence by: Based on; missed medication doses by days. Which poses a potential health and safety risk for those persons in care.
	POC Due Date: 12/16/2022
	Plan of Correction
1 2 3 4	Administrator to provide new training on the importance of administering medication to resdietns as prescribed by doctor. Administrator to provide copy of list of all the staff and signature who attended training and a brief description of the contents of the training provided. By POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	87411(c)(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	Administrator to provide a copy of new CPR card by POC due 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.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022

LIC809 (FAS) - (06/04)

Page: 4 of 7