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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603273
Report Date: 12/16/2021
Date Signed: 12/17/2021 08:25:09 AM

Document Has Been Signed on 12/17/2021 08:25 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BRADBOURNEFACILITY NUMBER:
198603273
ADMINISTRATOR:SMITH, JAYFACILITY TYPE:
735
ADDRESS:1332 BRADBOURNETELEPHONE:
(855) 302-3331
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 4CENSUS: 4DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Fernando Becerra, James Daniel Lopez &
Arejinea "Nae" Toney
Assistant Administrator / Joey Perez
Facility Manager / Juana "Ivett" Busby		TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff Members / Fernando Becerra, James Daniel Lopez and Arejinea "Nae" Toney and was later joined by the Assistant Administrator / Joey Perez and Facility Manager / Juana "Ivett" Busby who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled adults, ages 18 through 59 years old. The facility has an approved fire clearance for one (1) Ambulatory and three (3) Non-ambulatory clients (Total Census = 4). During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

LPA toured the physical plant areas inside and out to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. A tour of the single-story facility includes four (4) private bedrooms, two (2) bathrooms, a living room, dining room, kitchen, enclosed patio and indoor/outdoor activity areas. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.

The facility smoke alarm system and carbon monoxide detectors are hard wired. The smoke alarm system was tested and observed to be operational. There were a total of two (2) fire extinguishers, of which only one (1) was fully charged and in compliance. The facility does not have a fireplace. LPA observed the facility has perimeter fencing in the back yard. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There is no evidence of bodies of water (pool/spa) or security bars on the premises. LPA observed a shaded area with patio table and chairs for the clients. The facility has an attached one care garage which was converted to client bedroom #3 (Ambulatory). The washer and dryer are located in the enclosed patio. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to clients
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BRADBOURNE
FACILITY NUMBER: 198603273
VISIT DATE: 12/16/2021
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LPA observed chemicals and detergent soap were being locked and centrally stored in the storage unit located in the back yard. The facility has a camera system installed in the common areas of the facility (one located in the living room and one located in the enclosed patio).

Medications, sharps, client records, staff files and the First-Aid Kit are kept locked and centrally stored in the cabinet located in the hallway, near the kitchen and dining room area. A random selection of medications were reviewed to ensure they are being administered as prescribed. The first-aid kit is fully stocked w/First-aid Manual.

The following deficiencies were observed during today's visit;
  • The hot water temperature in bathroom #1 was measured at 125.3 degrees F.
  • Bedroom #4 was missing a smoke detector.
  • Cephalexin 500 MG (take one capsule by mouth four times daily for 10 days) was not administered to Client 1 (C1) on 12/15/21 (10pm dose) as the medication was inside the bubble pack and staff had not initialed the MAR (Medication Administration Record).
  • Lavela WS Supplement (Take 1 softgel three times a day) had already been initialed on the MAR for 12/16/21 (8pm dose) as administered to C1.
  • Per Assistant Administrator, Cephalexin 500 MG (take 2 capsules by mouth twice daily) was discontinued (DC'd) for C1 but there was no DC order in the file of C1.
  • The fire extinguisher located on top of the medication cabinet (dining room area) was empty and needed to be recharged/replaced.
  • All supplements being administered to C1 daily (per physician's orders), are missing labels.
  • LPA observed a missing window screen in bedroom #3.
  • LPA observed a missing closet door in bedroom #3.
  • The bathroom mirror cabinet was missing a door/mirror.
  • The shutters located near the dining area / bathroom #2 were broken/ in disrepair.


The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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Document Has Been Signed on 12/17/2021 08:25 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 12/16/2021 at 01:49 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADBOURNE
FACILITY NUMBER: 198603273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited

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Furniture, Fixtures, Equipment, and Supplies. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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This requirement is not met as evidenced by: The hot water temperature in bathroom #1 was measured at 125.3 degrees F. This poses an immediate health, safety risk to persons in care.
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Type A
12/17/2021
Section Cited

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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by: During a walk through of the facility, LPA observed that bedrrom #4 was missing a
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smoke detector. This poses an immediate health, safety risk to persons 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


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Document Has Been Signed on 12/17/2021 08:25 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 12/16/2021 at 02:08 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADBOURNE
FACILITY NUMBER: 198603273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited

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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by: Cephalexin 500 MG (take one capsule by mouth four times daily for 10 days) was not administered to Client 1 (C1) on 12/15/21
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(10pm dose) as the medication was inside
the bubble pack and staff had not initialed the MAR (Medication Administration Record). Also, Lavela WS Supplement (Take 1 softgel three times a day) had already been initialed on the MAR for 12/16/21 (8pm dose) as administered to C1. This poses an immediate health, safety risk to persons in care.
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Type A
12/17/2021
Section Cited

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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by: Per Assistant Administrator, Cephalexin 500 MG (take 2 capsules by mouth twice daily) was discontinued (DC'd) for C1 but there was
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no DC order in the file of C1. This poses an immediate health, safety risk to persons 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


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Document Has Been Signed on 12/17/2021 08:25 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 12/16/2021 at 02:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADBOURNE
FACILITY NUMBER: 198603273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited

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Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by: The fire extinguisher located on top of the
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medication cabinet (dining room area)
was empty and needed to be recharged/replaced. This poses an immediate health, safety risk to persons in care.
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Type B
12/23/2021
Section Cited

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Health Related Services. All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.


This requirement is not met as evidenced by: All supplements being administered to C1 daily (per physician's orders), are missing labels.
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This poses a potential health and safety risk to persons 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2021 08:25 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 12/16/2021 at 02:39 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADBOURNE
FACILITY NUMBER: 198603273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2021
Section Cited

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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by: During a walk through of the facility, the following deficiencies were observed;
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LPA observed a missing window screen in bedroom #3.
LPA observed a missing closet door in bedroom #3.
The bathroom mirror cabinet was missing a door/mirror.
The shutters located near the dining area / bathroom #2 were broken/in disrepair.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


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