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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601223
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:47:43 PM

Document Has Been Signed on 07/12/2022 03:47 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 FACILITYFACILITY NUMBER:
198601223
ADMINISTRATOR:AISHA ANDREWSFACILITY TYPE:
735
ADDRESS:4935 W. 136TH STREETTELEPHONE:
(310) 679-8977
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 6CENSUS: 6DATE:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Deborah DavenportTIME COMPLETED:
04:00 PM
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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-2022022508444. LPA observed deficiencies that is non-related to the complaint investigation visit conducted on 7/12/22. The following was discussed with direct care staff.
  • LPA observed metal foldable chairs to be full of dust and cobwebs, one chair's back rest was broken and seemed to be falling off from the frame and sticking out. LPA observed that client backyard patio seats are wood and framed, cushion were not on the patio seats. Staff states cushions are available however are in the garage. LPA observed one client sitting on the patio seat without a cushion.
  • LPA observed C1 bed didn't have a frame and the bed box and mattress were placed on the floor. Staff indicates C1 breaks the bed frames.
  • LPA observed that C1 has a five drawer cabinet for clothes, one drawer was missing and one drawer was hanging low and difficult to pull out.

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: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 07/12/2022 03:47 PM - It Cannot Be Edited


Created By: Jey Cardenas On 07/12/2022 at 03:05 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
MONTEREY PARK, CA 91754

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2022
Section Cited
CCR
80072(a)(2)

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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirment not met as evidenced by: Based on observation- 7/12/22 LPA observed backyard patio seating to be missing cushion
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Administrator is to replace C1 drawer, Clean/ dust patio seating & add cusions. And install bedframe to C1s bed. email to lpa.
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is dirty, and broken. LPA observed C1 bed without a bedframe, and drawer is broken and in ill repair. This poses a potential personal rights risk to clients in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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