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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603273
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:31:20 PM

Document Has Been Signed on 12/07/2023 04:31 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:PEREZ, JOEYFACILITY TYPE:
735
ADDRESS:1332 BRADBOURNETELEPHONE:
(855) 302-3331
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 4CENSUS: 4DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Anejinea Toney - CaregiverTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Anejinea Toney (Caregiver) and Joey Perez (Administrator) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory (3 of which may be non-ambulatory) clients ages 18-59. Facility currently has 4 ambulatory clients serviced by San Gabriel/Pomona Regional Center.

The facility is a single-story home located in a residential area in Duarte, Ca. A tour of the facility includes: 4 bedrooms, 2 bathrooms, living room, kitchen, dining area, laundry closet, office area, front yard, back yard and locked toolshed.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.


Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are centrally stored yet readily available for clients. The hot water temperature in both client bathrooms were tested and within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. During tour LPA observed laundry detergent to be out and unlocked within the laundry area/closet, details cited on 809-D page. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: The facility maintains an approved fire clearance and conduct regular fire/earthquake drills. Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 12/07/2023 04:31 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/07/2023 at 04:01 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: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during facility tour LPA observed laundry detergent to be left unattened on top of washer in an open laundry closet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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**Administrator removed laundry detergent and placed in locked tool shed with all other chemicals during visit**
Licensee to conduct a training with all staff, covering proper storage of disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients. A copy of the training log with participants signatures and training materials to be emailed to LPA by 12/22/23.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2023 04:31 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/07/2023 at 04:01 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: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff files wre missing the required First Aid certificae, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Licensee to ensure all staff have proper first aid training within their personnel files and submit a copy of Staff #1 First Aid certificate via email to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


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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: 12/07/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a locked cabinet, LPA reviewed 5 staff files during today’s visit, 1 out of 5 staff files were missing their first-aid certificate, all other files reviewed have criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Joey Perez certificate expires on 12/17/2024.
Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides internet and telephone landline for the clients.
Client Records-Incident Reports: Client files are maintained in a secured location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 clients medications and there were no issues observed.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. The last Fire/Emergency Drill was conducted during visit on 12/7/23.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview was held and a copy of the report was provided to Administrator Joey Perez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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