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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603273
Report Date: 12/10/2022
Date Signed: 12/10/2022 03:16:11 PM

Document Has Been Signed on 12/10/2022 03:16 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
GREATER LA AC/SC, 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:
12/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Administrator Joey PerezTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced site visit for the Required - 1 Year Inspection utilizing the Infection Control Tool. LPA met with DSP Terry Jelk and explained the reason for the visit. Licensee Jason Smith arrived shortly thereafter. Physical Plant was toured, sample record of medications was reviewed, and food supply was inspected. The facility has an approved fire clearance for one (1) Ambulatory and three (3) Non-ambulatory clients. The facility is licensed to serve four (4) Developmentally Disabled adults, ages 18 through 59 years old. There are four (4) level 4I developmentally disabled clients in the home. All clients receive services through San Gabriel Valley/Pomona Regional Center. Administrator’s Certificate expires on 12/17/22 however, proof of pending status was provided. Fire drill was last conducted on 11/23/22.

The facility is a single-story home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, kitchen, living room/dining area, shaded patio area, and shed.

Observations:

· COVID-19 Infection Control signs were observed in the entrance and bathrooms. Screening protocols are in place. Clients in care do not wear a mask because it is not tolerated due to cognitive impairment.


· Four (4) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked file cabinet.
· A posted Emergency Disaster Plan was observed. Smoke detectors were tested and are operational. Fire extinguisher near kitchen was not fully charged. Fire extinguisher in laundry room was fully charged.
Sufficient supply of Personal Protective Equipment (PPEs) was observed.

CONT 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2022
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 12/10/2022 03:16 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/10/2022 at 02:30 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: 12/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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:
Deficient Practice Statement
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Based on observation, fire extinguisher near kitchen was not fully charged, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2022
Plan of Correction
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Administrator/Licensee will provide receipt of new fire extinguisher and photo proof of new extinguisher. During visit, Licensee purchased 2 new fire extinguishers and provived receipt only.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2022


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BRADBOURNE
FACILITY NUMBER: 198603273
VISIT DATE: 12/10/2022
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  • Water temperature in kitchen was measured at 113.1 degrees F which is within in the required 105-120 degrees F. Sharps and chemicals/cleaning supplies are stored inaccessible to residents.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • Water temperature in client bathroom was measured at 108.8 degrees F which is within the required degrees of 105-120 degrees F.
  • Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen, and the linen is in good condition. Each client bedroom is designated as a COVID-19 isolation room if needed.

Deficiencies are being cited. See LIC 809D.
Exit interview was conducted with Administrator Perez. A copy of the report/appeal rights was issued
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022
LIC809 (FAS) - (06/04)
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