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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802108
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:41:22 PM

Document Has Been Signed on 05/06/2024 03:41 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 FACILITYFACILITY NUMBER:
197802108
ADMINISTRATOR/
DIRECTOR:		SIOKKHING SMITHFACILITY TYPE:
735
ADDRESS:500 S. MCPHERRIN AVETELEPHONE:
(626) 307-8896
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 6DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:24 PM
MET WITH:In H Lim, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:49 PM
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Licensing Program Analyst (LPA) Alberto Lopez 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 was greeted by In Kim, Administrator and assisted with the visit. LPA explained the purpose of the visit.

The facility is licensed to serve 6 non-ambulatory and developmentally disabled clients aged 18 to 59. Currently, there are four (4) clients in placement. One (1) clients are over 60 years of age. All clients are provided Case Management services by East Los Angeles Regional center.

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves.
while assisting clients. Staff are disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Fire Drills are conducted every six months; the last fire drill was conducted on 12/12/2023 Emergency Disaster/ Earthquake Drills are conducted every 6 months and the last one was conducted on date unknown. (no documentation that one has been conducted)

LIC 809C for continuation of report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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: 05/06/2024
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Physical Plant & Environment Safety: The facility has 4 client bedrooms, including 2 shared rooms, 2 bathrooms, additional bedroom with bathroom designated as an isolation room, living room, dining room, kitchen, and an attached garage. and indoor/outdoor activity areas. 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 CCL 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 measured 105.4– 106.3.8 degrees F which is within range of 105.0 – 120.0 F. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. Some kitchen cabinets were uncleaned. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors 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, are fingerprint and cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Administrator, and S1-7. 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. Administrator certificate expires 10/30/2024.

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



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. Facility kitchen area is kept clean and free from rodents and other bugs/insects. Plates, cups, and utensils are kept cleaned and stored properly.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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: 05/06/2024
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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, 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. Physician's Report for the Elderly LIC602a is missing for 1 clients over 60 years of age.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for 6 clients. 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. Labels are missing for PRN medications.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services.

Disaster Preparedness: The facility has an Emergency Disaster Plan but needs updating.

Emergency Intervention: Not Applicable.

No deficiencies noted. Technique advisories provided. Exit interview and a copy of this report, and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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