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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320096
Report Date: 06/01/2021
Date Signed: 06/03/2021 03:15:49 PM

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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:BRICKSTONE MANORFACILITY NUMBER:
198320096
ADMINISTRATOR:DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:20551 MADISON ST.TELEPHONE:
(310) 251-2382
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 6DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:MUQUEET DADABHOY/VIRGILIO PASCUALTIME COMPLETED:
01:30 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
On 6/1/2021 at 9:29 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called Licensee Muqueet Dadabhoy and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. The facility has an approved mitigation plan report.

The facility is licensed for six (6) ambulatory residents, of which six (6) may be bedridden and an approved hospice waiver for six (6) residents. Currently, present in the home are two non-ambulatory and four ambulatory residents of which one resident is in hospice care.

At around 9:45 am, LPA met with the House Manager, Virgilio Pascual, and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. The licensee Muqueet Dadabhoy and assistant administrator Edilberto Bernardino arrived later and joined the visit.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio in addition to the resident’s bedroom. LPA observed staff maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

LPA reviewed the facility’s surveillance testing records, the last Covid-19 test for staff was conducted in March 2021 and discontinued the surveillance testing. A review of vaccination and N-95 Fit Testing records was conducted. All staff and residents have been vaccinated with Covid-19. None of staff has completed the N-95 fit testing. The facility has not conducted a Covid-19 Infection Control and Prevention training to any staff. An emergency contact list was reviewed.

REPORT CONTINUED IN LIC 809-C

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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 4
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
VISIT DATE: 06/01/2021
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
All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Furniture in the living room are separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature was measured at 117 and 113 degrees F in the common bathrooms. A comfortable temperature was maintained in the facility.

At around 9:55 am, LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. LPA observed residents' vitamins/PRN medications without prescriptions and labels. The First Aid kit was available. One fully charged fire extinguisher last serviced 4/27/2021 was observed in the kitchen. At 10:14 am, LPA observed a missing smoke detector in resident bedroom #1 and no carbon monoxide was observed. Licensee installed a surveillance camera in common areas without prior notice to CCLD.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Advisory Notes were issued, and Technical Assistance was provided.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed.

Due to technical difficulties, advisory notes, citations and appeal rights will be emailed to the licensee by end of business today.

An exit interview was conducted, and a copy of this report was provided to the House Manager, Virgilio Pascual.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
LPA observed and took a photo of a missing smoke detection from its base in resident bedroom #6. Also, based on LPA's observation and interview with the house manager, there was no carbon monoxide in the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2021
Plan of Correction
1
2
3
4
Licensee agreed to install/replace the missing smoke detector in resident bedroom #6 and install a carbon monoxide in the facility by the POC due date. Licensee will send a photo and a video of a working smoke detector in resident bedroom #6 and a carbon monoxide in the common area of the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: BRICKSTONE MANOR
FACILITY NUMBER: 198320096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance: All individuals subject to a criminal record review pursuan to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, interview and record review, Staff #1 & Staff #2 were permitted to work in the facility without a transfer request of their criminal record clearance. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
1
2
3
4
Licensee agreed to submit to CCLD a request to transfer the criminal record clearance of Staff #1 & #2 by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4