198601222-3-20-2023-11-AS-MLEN-CQ4V5N-20230320160814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601222
Report Date: 03/20/2023
Date Signed: 03/20/2023 04:08:27 PM

Document Has Been Signed on 03/20/2023 04:08 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BRIDGE I ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198601222
ADMINISTRATOR:	AISHA ANDREWS		FACILITY TYPE:	735
ADDRESS:	13817 CASIMIR AVENUE		TELEPHONE:	(310) 327-9501
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY: 6		CENSUS: 5	DATE:	03/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Brenda Davenport - House Manager		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) Mario Leon conducted an unannounced Annual required visit to review the physical plant and review client and staff records. LPA was met by House Manager, Debra Davenport (HM1) and the purpose of today’s visit was explained. LPA Leon reviewed the physical plant, medications, food service, clients and staff records, consumer IPPs, and staffs first aid certificates, verified that the Administrator, Tiara Dancy, is present at the property 20+ hours per week. LPA Leon verified all current staff fingerprints cleared/associated to the facility. The facility annual fees are current. There are currently five (5) Westside Regional Center (WRC) consumers in placement. LPA and HM1 toured the physical plant. The facility is a single story, three (3) bedrooms, two (2) bathrooms’ corner house located in a residential neighborhood. The facility has a living room, dining room, kitchen, family room, laundry room, attached garage, shaded area, indoor/outdoor activity areas. Bedrooms #1-3 are designated as client bedrooms. Both bedrooms number two (2) and three (3) have two clients to a room, bedroom one (1) is currently private . There are no bodies of water or firearms/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational and were within Title 22 regulations. The water temperature measured 117.6 F in bathroom number two ( #2) and a comfortable temperature is maintained in the facility at 69.8 F. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. See LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRIDGE I ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601222
	VISIT DATE: 03/20/2023

NARRATIVE

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First aid kit is fully stocked with manual, working telephone, smoke detectors were in compliance, carbon monoxide needs to be updated, fire extinguishers are fully charged as of 03/09/23 and last fire/emergency drill conducted on February 06, 2023.

During today's visit, there was one deficiency cited. See LIC809-D.

An exit interview was conducted and copies of this report, the deficiency and appeal rights were provided to House Manager Debra Davenport .

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2023 04:08 PM - It Cannot Be Edited

Created By: Mario Leon On 03/20/2023 at 03:50 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRIDGE I ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1503.2

General Provisions

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in that the carbon monixide located in living room was in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	House Manager and LPA have agreed that on, or prior to, the POC due date, facility will submit media evidence (video) via email to LPA at Mario.Leon@DSS.CA.GOV.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Mario Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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