197802108-7-6-2023-28-AS-AGOZ-CTGVAY-20230706161644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802108
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:16:49 PM

Document Has Been Signed on 07/06/2023 04:16 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:	PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	197802108
ADMINISTRATOR:	SIOKKHING SMITH		FACILITY TYPE:	735
ADDRESS:	500 S. MCPHERRIN AVE		TELEPHONE:	(626) 307-8896
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91754
CAPACITY: 6		CENSUS: 6	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	In H Lim		TIME COMPLETED:	04:30 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) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Administrator In H Lim and explained the purpose for the visit. The facility is licensed to serve 6 ambulatory developmentally disabled clients age 18 to 59. Currently, there are six (6) clients in placement, there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by East Los Angeles Regional Center. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Administrator all six (6) clients have COVID-19 vaccines including boosters. Per Administrator, all staff also have the COVID-19 vaccines including boosters. Facility is adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802108
	VISIT DATE: 07/06/2023

NARRATIVE

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Operational Requirements: Fire Drills are conducted every six months, the last fire drill was conducted on 6/18/23. Emergency Disaster/ Earthquake Drills are also conducted every six months and the last one was conducted on 6/18/23. Facility is adhering to operational requirements.

Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility includes: 5 client bedrooms, 2 bathrooms, additional bedroom with bathroom designated as an isolation room, living room, dining room, kitchen, and an attached garage. Laundry appliances located in the garage. There are no obstructions to the passageways and no bodies of water. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen and mattresses and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries accessible to clients. Water temperature properly measured at 105 degrees F. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished. 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 clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, facility sketch, visitor policy, complaint procedures, menu and emergency disaster plan.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-2. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting.

Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802108
	VISIT DATE: 07/06/2023

NARRATIVE

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Client Rights-Information: Client personal rights and House Rules are posted. Per Administrator, facility provides wi-fi services for facility clients.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C6. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights and current IPPs.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-6. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor any client that has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention : Not-Applicable.

No deficiencies noted. Exit interview and a copy of this report was provided to Administrator In H Lim.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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