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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601223
Report Date: 11/07/2022
Date Signed: 11/15/2022 09:27:12 AM

Document Has Been Signed on 11/15/2022 09:27 AM - 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 II ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601223
ADMINISTRATOR:AISHA ANDREWSFACILITY TYPE:
735
ADDRESS:4935 W. 136TH STREETTELEPHONE:
(310) 679-8977
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 6CENSUS: 6DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:TIME COMPLETED:
03:45 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 November 7, 2022, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced 1-year Annual Inspection using CARE tools. LPA Gibbs met with facility representative Turani Baturay (Support Staff) and Debra Davenport (Supervisor) and explained the purpose of the visit. The facility is licensed for 6 ambulatory Developmentally Disabled adults ages 18-59. Currently the house has 6 residents. LPA toured the facility with Debra Davenport.

Structure The facility is a single story residential house. The house consists of (3) client bedrooms, (1.5) bathrooms, living room, dining room, kitchen, den room, an outdoor patio/ backyard, and garage/ storage room.

Physical Plant Outside grounds were toured. All walkways and exits were free of obstructions and debris. There were a table and chairs available. No bodies of water were observed.

Bedroom Each bedroom was inspected and contain the required furniture. They had a chair, night stand, lamp, dresser for each client and sufficient closet space. Each bed had a mattress cover, bottom and top sheet, blanket, comforter, and pillows with pillowcases.

Bathrooms The toilets, shower and sinks are all in working order. The shower has a nonskid mat. LPA observed soap, paper towel and other hygiene products fully stocked. Trash cans have lids. Water temperature in the bathroom 1 measured 118.7 and bathroom 2 measured 118.6 degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 2
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 II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601223
VISIT DATE: 11/07/2022
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
Linens & Hygiene LPA observed that the facility has a fully stocked bedding, towels, and hygiene products in the closet.

Common Spaces The living room, den room and dining room have adequate lighting and enough seating for everyone. LPA observed games for residents.

Kitchen All appliances are in good working condition. Dishes, cups, silverware, pots, and pans all in good order. Knives are kept in a lock cabinet in the kitchen. Kitchen sink water temperature measured 119.8 degrees Fahrenheit. Trash cans are covered to allow proper disposal of waste. There is sufficient supply of non-perishable and perishable foods available.

Medications LPA observed medications are stored in a locked cabinet in the kitchen. LPA went through facility MARs and medication for 3 residents.

First Aid & Drills First Aid kit kept in a cabinet in the den and needs refilled of some products and a manual. Smoke detectors and carbon monoxide detectors were tested and are properly functioning. Last disaster drill was on 11/04/22. LPA observed a fire extinguisher that was fully charged.

Record Review LPA reviewed 3 residents records and 4 staff records. All records contained required documentation. LPA reviewed surety bond.


Emergency Numbers & Info All necessary signs posted including Covid prevention and “See something, say Something,” and facility license. LPA observed emergency exit plan and emergency numbers posted.

All toxins are locked/secured and inaccessible to clients.

There were no deficiencies issued during this visit under the California Code of Regulations requirements per Title 22.

Exit interview, a copy of the licensing report provided to Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2