<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802108
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:46:18 PM

Document Has Been Signed on 08/23/2021 01:46 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PACIFIC BRIDGE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197802108
ADMINISTRATOR:SIOKKHING SMITHFACILITY TYPE:
735
ADDRESS:500 S. MCPHERRIN AVETELEPHONE:
(626) 307-8896
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 6DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:In Lim (Administrator)TIME COMPLETED:
02:00 PM
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) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with In Lim (Administrator) and explained the purpose of the visit. Licensee prefers to serve developmentally disabled adults 18 through 59 years, ambulatory only.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, office, kitchen, dining area, 1 Staff bedroom, 1 Staff bathroom, 4 Client bedrooms, 2 and 1/2 client bathrooms and 1 attached garages/laundry room.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen closet. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Fully charged fire extinguisher is mounted to the dining room wall. Smoke and Carbon Monoxide detectors are operable. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance. Staff responsible for direct care and supervision have current first aid. Clients list of their Personal Rights were observed. LPA was allowed to enter the facility to conduct the inspection. The Administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Continue to LIC809C.......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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 2
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: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197802108
VISIT DATE: 08/23/2021
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
Medications are safe, locked and accessible to Staff. Hot water temperature measured within guidelines in bathroom #1.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to In Lim.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2