198601223-3-7-2023-11-AS-WGIS-CPPV4F-20230307150615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601223
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:06:20 PM

Document Has Been Signed on 03/07/2023 03:06 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 II ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198601223
ADMINISTRATOR:	AISHA ANDREWS		FACILITY TYPE:	735
ADDRESS:	4935 W. 136TH STREET		TELEPHONE:	(310) 679-8977
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 6		CENSUS: 6	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Tiara Dancy		TIME COMPLETED:	03:15 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 03/07/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced 1-year Annual Inspection using the full CARE tools. LPA met with Direct Support Professional, Markeisha (Kelli) Findley and Assistant Administrator, Tiara Dancy 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, and 2 were present during the visit, 3 residents were at day program and 1 was on an outing at family’s home. LPA toured the facility with Tiara Dancy. Structure The facility is a single-story home in a residential neighborhood. 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 LPA toured the outside grounds of the facility. All walkways and exits were free of obstructions and debris. There were a table and chairs available. LPA observed no bodies of water were on the premises. There is a fireplace located in the den, LPA observed it to be covered with a screen and inaccessible to residents. Bedroom LPA inspected all bedrooms and found they contained the required furniture, including beds, dressers, nightstands, chairs, and ample storage space for personal belongings. LPA observed all beds had the required linens including mattress cover, fitted sheets, blankets, comforter, and pillow. Bathrooms The toilets, shower and sinks are all in good working order. The shower has a nonskid material and a seat. Safety handrails are securely fastened. 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. Both bathrooms were observed to be clean and sanitary. Linens & Hygiene LPA observed and ample supply of bed linens, and towels stored in a cupboard in the hallway. Resident’s personal hygiene products are stored in a closet in the den. Common Spaces LPA inspected all common spaces in the facility. In the den, LPA observed ample seating to accommodate all residents. There is a selection of activities in the facility for residents. LPA observed a large rectangular table and enough chairs to accommodate all residents. In the living room, LPA observed a

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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 II ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198601223
	VISIT DATE: 03/07/2023

NARRATIVE

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couch, and multiple single seating chairs, to accommodate all residents. All rooms and hallways had adequate lighting. LPA observed all walkways to be clean, clear, and free of obstructions and hazards. A comfortable temperature was maintained in the facility.
Kitchen LPA observed all appliances to be in good working repair. LPA observed all cutleries, pots and pans were observed to be in good repair. Sharps are secured 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. LPA observed a 3-day supply of perishable food and a 7-day supply of nonperishable. All cleaning supplies are securely stored in a cupboard in the laundry room and are inaccessible to residents. An additional supply of nonperishable food is stored in a freezer in the garage. LPA observed an emergency water supply in the garage.
Medications LPA reviewed all resident’s medications and matched them to the MARs. All medications are secured in a cabinet in the laundry room and are inaccessible to residents.
Safety LPA observed a fully stocked First Aid kit secured in a closet in the den and kitchen, and a manual. Smoke detectors were fully functioning and operable. The carbon monoxide detector is located in the hallway and is fully functioning. The facilities last emergency drill was on 02/28/23. LPA observed 2 fully charged fire extinguisher, one in the kitchen and the other mounted on the wall in the den, last serviced on 02/25/22. LPA observed a working landline telephone. LPA observed all required postings, including Emergency Plan, emergency numbers, facility sketch, Personal Rights, menu, schedule, and complaint information. There are no firearms or ammunition stored on the premises.
File Review LPA reviewed 6 residents files and observed they contain the required documents. LPA reviewed 5 staff files and observed they contained the required documents, training, and certification. LPA conducted 5 resident interviews and 2 staff interviews. LPA reviewed the facilities Surety Bond through Platte River Insurance Company which expires on 02/09/24.
Infection Control LPA observed the facilities infection control procedures. At the entrance is a visitor log, thermometer, hand sanitizer and masks. All visitor, staff and resident’s temperature is taken upon entry and logged. LPA observed infection control signs posted throughout the facility. LPA observed a 60-day supply of PPEs stored in the garage.
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: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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