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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603738
Report Date: 07/28/2022
Date Signed: 08/01/2022 10:55:41 AM

Document Has Been Signed on 08/01/2022 10:55 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BANCROFT HOUSEFACILITY NUMBER:
197603738
ADMINISTRATOR:PHILLIPS, ROBINFACILITY TYPE:
735
ADDRESS:1595 BANCROFT STTELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 6DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff / Ana Rodriguez
Administrator / Maggie Estrada		TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility LPA met with Staff / Ana Rodriguez and was later joined by the Administrator / Maggie Estrada who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years of age. The facility is approved for six (6) Ambulatory Clients only. Currently, there are six (6) clients in placement. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

There is only one entrance being utilized at the facility. COVID -19 related materials were posted on the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility is located in a residential area. A tour of the single-story facility includes: Three (3) client bedrooms, 1 (one) office, two (2) bathrooms, living room, kitchen / dining area, laundry room and indoor/outdoor activity areas. All medications for residents who need assistance are kept locked and inaccessible to other residents. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to residents. There is a functioning telephone on the premises. The facility has central air and heating accommodations. LPA reviewed client medications.



Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. The
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BANCROFT HOUSE
FACILITY NUMBER: 197603738
VISIT DATE: 07/28/2022
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front yard is well landscaped with steps that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There is no evidence of bodies of water (pool) nor weapons on the premises. There is a detached garage which is being used for storage and is kept unlocked. The office is kept locked and inaccessible to clients at all times.

During today's walk through, LPA observed COVID-19 prevention/protocol signs posted throughout the facility.

The following concerns were observed during today's visit;

  • At 2pm, the hot water temperature in the kitchen was measured at 121 degrees F.
  • At 2:25pm, LPA discovered that medications Megestrol Acetate 40MG Tablet (2 tablets by mouth twice daily to stimulate appetite) and Ensure Original Vanilla Liquid (drink 1 can by mouth three times daily in between meals for supplement) were missing from the facility and not being administered to Client #1 (C1) per physician's orders.
  • At 2:25pm, LPA discovered that PRN medication Ibuprofen 800 MG Tablet (1 tablet by mouth every 6 hours as needed for pain) was missing from the facility and not being administered to C1 per physician's orders.

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/01/2022 10:55 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 07/28/2022 at 02:47 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BANCROFT HOUSE
FACILITY NUMBER: 197603738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited

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Furniture, Fixtures, Equipment, and Supplies.
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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This requirement is not met as evidenced by:
At 2pm, the hot water temperature in the kitchen was measured at 121 degrees F. This poses an immediate health and safety concern for the residents in care.
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Type A
07/29/2022
Section Cited

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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
At 2:25pm, LPA discovered that medications Megestrol Acetate 40MG Tablet (2 tablets by mouth twice daily to stimulate appetite) and
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Ensure Original Vanilla Liquid (drink 1 can by mouth three times daily in between meals for supplement) were missing from the facility and not being administered to Client #1 (C1) per physician's orders.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/01/2022 10:55 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 07/28/2022 at 02:58 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BANCROFT HOUSE
FACILITY NUMBER: 197603738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited

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Health Related Services. Once ordered by the physician the medication is given according to the physician's directions.


This requirement is not met as evidenced by;
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At 2:25pm, LPA discovered that PRN medication Ibuprofen 800 MG Tablet (1 tablet by mouth every 6 hours as needed for pain) was missing from the facility and not being administered to C1 per physician's orders.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
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