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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601222
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:43:33 PM

Document Has Been Signed on 03/04/2024 12:43 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BRIDGE I ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601222
ADMINISTRATOR:AISHA ANDREWSFACILITY TYPE:
735
ADDRESS:13817 CASIMIR AVENUETELEPHONE:
(310) 327-9501
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 5DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Debra Davinport, Residential ManagerTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Felisa Shirley and Troy Watson 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’s Felisa and Troy and House Manager Debra Davenport 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.

LPA’s Felisa, Troy and Debra walked through the kitchen and all appliances were in good working order. Knives were locked and stored in the drawer in the kitchen, medications were locked in the drawer in the kitchen inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 110.9 degrees Fahrenheit.

LPA observed the facility is clean, sanitary, and in good repair. Indoor and outdoor passageways and other areas of potential hazard are free of obstructions. Facility temperature is between 68° degrees and 85° degrees. Open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Carbon monoxide/Smoke detectors operate properly.

There are ample amounts of first-aid supplies and first-aid manual. There is working washer and dryer located on the service porch.

con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRIDGE I ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601222
VISIT DATE: 03/04/2024
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The backyard is clean and clear of obstructions and hazards and there are no bodies of water present.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of this report was provided to House Manager, Debra Davenport

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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