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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601223
Report Date: 03/08/2024
Date Signed: 03/08/2024 11:56:47 AM

Document Has Been Signed on 03/08/2024 11:56 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Debra Davenport-Residential Program ManagerTIME COMPLETED:
12:30 PM
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On 03/08/2024, Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual Inspection using the full CARE tools. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA España was granted access and allowed to enter the facility to conduct inspections. LPA España met with Debra Davenport, Residential Manager and explained the purpose of the visit. LPA reviewed Six (6) out of Six (6) client files. LPA España interviewed One (1) out of Two (2) staff members. The Adult Residential Facilities (ARF) facility is licensed for Six (6) ambulatory Developmentally Disabled adults ages 18-59. Currently the house has Six (6) clients, and Three (3) were present during the visit, Three (3) clients were at the day program.All Six (6) clients are Westside Regional Center placement. LPA España toured the facility with Debra Davenport-Residential Program Manager. The facility is a single-story home in a residential neighborhood. The house consists of Three (3) client bedrooms, One point five (1.5) bathrooms, One (1) living room, One (1) dining room, One (1) kitchen, One (1) den room, an outdoor patio/ backyard, and garage/storage room.
FACILITY EVALUATION REPORT (Cont)
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601223
VISIT DATE: 03/08/2024
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LPA España 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 España observed no bodies of water were on the premises. There is a fireplace located in the den, LPA España observed it to be covered with a screen and inaccessible to clients. LPA España inspected all bedrooms and found they contained the required furniture, including beds, dressers, nightstands, chairs, and ample storage space for personal belongings. LPA España observed all beds had the required linens including mattress cover, fitted sheets, blankets, comforter, and pillow. 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 España observed soap, paper towel and other hygiene products fully stocked. Trash cans have lids. Water temperature in the bathroom One (1) measured 118.7 degrees Fahrenheit and bathroom Two (2) measured 118.6 degrees Fahrenheit. Both bathrooms were observed to be clean and sanitary. LPA España observed an ample supply of bed linens, and towels stored in a cupboard in the hallway. Client’s personal hygiene products are stored in a closet in the den. LPA España inspected all common spaces in the facility. In the den, LPA España observed ample seating to accommodate all clients. There is a selection of activities in the facility for clients. LPA España observed a large rectangular table and enough chairs to accommodate all clients. In the living room, LPA España observed a couch, and multiple single seating chairs, to accommodate all clients.All rooms and hallways had adequate lighting. A comfortable temperature was maintained in the facility. FACILITY EVALUATION REPORT (Cont)
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601223
VISIT DATE: 03/08/2024
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LPA España observed all appliances to be in good working repair. LPA España observed all cutleries, pots and pans were observed to be in good repair. Sharps are secured in a lock cabinet in the kitchen. The kitchen sink water temperature measured 119.8 degrees Fahrenheit. Trash cans are covered to allow proper disposal of waste. LPA España observed a 2-day supply of perishable food and a 7-day supply of nonperishables. All cleaning supplies are securely stored in a cupboard in the laundry room and are inaccessible to clients. An additional supply of nonperishable food is stored in a freezer in the garage. LPA España observed an emergency water supply in the garage. LPA España reviewed all client’s medications and matched them to the MARs. All medications are secured in a cabinet in the laundry room and are inaccessible to clients. LPA España 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 02/05/24. LPA España observed Two (2) fully charged fire extinguishers, one in the kitchen and the other mounted on the wall in the den, last serviced on 02/25/24. LPA España observed a working landline telephone. LPA España 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. LPA España reviewed Six (6) client files and observed they contain the required documents. LPA España reviewed Five (5) staff files and observed they contained the required documents, training, and certification. FACILITY EVALUATION REPORT (Cont)
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601223
VISIT DATE: 03/08/2024
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LPA España reviewed the facilities Surety Bond through Platte River Insurance Company with an effective date of 03/01/2024. LPA España observed the facilities infection control procedures.

Exit interview, a copy of the licensing report provided to Debra Davenport-Residential Program Manager.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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