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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603738
Report Date: 01/10/2025
Date Signed: 01/10/2025 03:42:08 PM

Document Has Been Signed on 01/10/2025 03:42 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/
DIRECTOR:
PHILLIPS, ROBINFACILITY TYPE:
735
ADDRESS:1595 BANCROFT STTELEPHONE:
(626) 794-4103
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 7DATE:
01/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Maggie Estrada, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan made an unannounced case management visit regarding a self-reported incident on the relocation of 2 clients from Harriet House #198602362 to Bancroft House #197603738 due to mandatory evacuation orders from the Fire Advisory. LPA met with Administrator, Maggie Estrada, and explained the reason for the visit.

During the visit today, LPA Chan conducted a health and safety check, and no concerns were observed. LPA obtained a copy of the client and staff roster for Bancroft House. There were no rosters available for Harriet House. The last fire drill was conducted on 12/13/24.

Per interview with the administrator, there are 2 clients that have been relocated from Harriet House and 5 clients from Bancroft House. They have sufficient staffing to meet the needs of the clients. Food and hygiene supplies are available to accommodate a total of 7 clients. The facility has 3 bedrooms, 1 staff office, 2 bathrooms, living room, dining area, and kitchen. The medications and MAR logs for the 2 individuals from Harriet House were transferred to the facility and are centrally stored and locked. All the clients in the facility are ambulatory and do not use any assisted devices. Administrator stated the families, responsible parties, and regional center for Harriet House clients have been notified of their relocation.

LPA informed administrator to notify the local fire authority of the over capacity and to submit an incident report to appropriate agencies.

An exit interview was held and a copy of this report was given to the administrator.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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