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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601223
Report Date: 02/25/2022
Date Signed: 02/25/2022 06:44:30 PM

Document Has Been Signed on 02/25/2022 06:44 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY 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:
02/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:DSP- FindleyTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jey Cardenas completed a case management visit to the above facility; during a site visit regarding a complaint investigation control number 11-AS-20220225084441. During this visit LPA observed deficiencies that is non-related to the complaint investigation conducted on 2/25/2021. The following was discussed with the Administrator, and direct care staff;
  • LPA observed facility walls throughout the facility have dirt and dust .
  • LPA observed smoke detector in the hallway is missing, one smoke detector in room1 is hanging by the wires, and LPA heard chirping coming from smoke detector.
  • LPA observed blinds throughout the facility are broken, slates are missing/ broken. LPA observed Room#1 drawers are missing, one drawer is hanging and doesnt not slide open easily.
  • LPA observed food items are taken out of original packaging and not labeled- Fruit Loops are taken out of the original box, and transfered to a plastic storage container which is not labeled.
Per California Code of Regulations, Title 22 the following deficiencies were observed and cited: (Refer to LIC 809-D)

Exit interview conducted, appeal rights issued, and a copy of the report was provided.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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Document Has Been Signed on 02/25/2022 06:44 PM - It Cannot Be Edited


Created By: Jey Cardenas On 02/25/2022 at 02:18 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
MONTERY PARK, CA 91754

FACILITY NAME: BRIDGE II ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2022
Section Cited
CCR
80087(a)

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80087(a) Buildings & Grounds
e facility shall be clean, safe, sanitary and in good repair...This requirement is not met as evidenced by: Based on observation, smoke detectos were missing, hanging and heard detector chirping in the facility. This poses an immediate risk to clients.
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Administraor will ensure all smoke detectors through the facility are in working condition and installed in rooms, hallway. Take picutes of detectors and email to LPA by POC.
Type B
03/08/2022
Section Cited
CCR
80087(a)

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80087(a) Buildings & Grounds
e facility shall be clean, safe, sanitary and in good repair...This requirement is not met as evidenced by: Based on observation, LPA saw dirt&dust on walls/ doors throughout facility. Window blinds are broken. This poses potential personal rights risk clients.
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Administrator will ensure facility walls, doors, ceiling, is free of dirty and dust and all blinds are in repair. Email picture of all window blinds and walls thoughout facility.
Type B
02/25/2022
Section Cited
CCR80076(a)(1)

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Food Service. Meals shall be at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - for the age group served, and that foods shall be selected, stored, prepared and served in a safe and healthful manner. This requirement not met as evidenced; based on LPAs observation
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Administrator will conduct inserive training with staff regarding food services. Submit training logs with staff signature attesting training was provided.
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LPA observed food items removed from original packaging to storage container. Itmes were not labeled.
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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