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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603738
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:27:09 PM

Document Has Been Signed on 11/15/2023 12:27 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
GREATER LA AC/SC, 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: 5DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Magdalena "Maggie" EstradaTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Magdalena “Maggie” Estrada (Administrator) and explained the reason for the visit. The facility is licensed to serve 6 ambulatory only clients ages 18-59. Facility currently has 5 ambulatory clients serviced by Frank D. Lanterman Regional Center.

The facility is a single-story home located in a residential area in Pasadena, Ca. A tour of the facility includes: living room, dining room, dining/activity area, kitchen, laundry area, 2 bathrooms, 3 client bedrooms, 1 office, detached garage, front yard and back yard.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.


Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature in both client bathrooms was tested and measured between 117.5-118.2 degrees F and which is within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. During visit weather changed (began to rain) and LPA observed a leak in the hallway ceiling/roof (details will be cited on 809-D).LPA did another tour to ensure no leaks present in clients bedrooms, there were none.

(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BANCROFT HOUSE
FACILITY NUMBER: 197603738
VISIT DATE: 11/15/2023
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Operational Requirements: The facility maintains an approved fire clearance and conduct regular fire/earthquake drills. Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use, however, there was no shaded area to meet the requirement details will be cited on the 809-D.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained within the staff office. LPA reviewed 5 staff files during today’s visit with no issues. Each file reviewed have criminal record clearance, current First Aid/CPR/AED and sufficient on-going training. Administrator Maggie Estrada certificate expires on 3/28/25.
Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides internet and telephone land line for the clients.
Client Records-Incident Reports: Client files are maintained within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files today with no issues.
Food Service: 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.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 5 clients medications and there were no issues observed.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. The last Fire/Emergency Drill's were conducted on 10/04/23 (fire) & 10/11/23 (emergency).
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.
LPA conducted 1 staff interviews and 0 client interviews as clients were at day program during visit.
Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D).
Exit interview was held and a copy of the report was provided to Administrator Maggie Estrada.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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Document Has Been Signed on 11/15/2023 12:27 PM - It Cannot Be Edited


Created By: Tena Herrera On 11/15/2023 at 11:49 AM
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: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during facility tour LPA observed back yard to have furnishing/outdoor seating area but missing required shaded area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator to speak with licensee and obtain the required shading for clients in care. Administrator to take photos of back yard with required seating and shaded area and provide photos to LPA via email by POC due date.
Type B
Section Cited
CCR
80087(a)

80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during visit, it started to rain and a leak from ceiling appeard within the hallway inside the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Administrator to arrange for repairs to be made to roof and ceiling and provide proof of repairs to LPA via email by POC due date. A Special Incident Report shall be submitted to licensing via fax with scheduled date and time of repairs along with all other relevant information pertaining to repair.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


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