198603273-12-3-2024-28-AS-ALOZ-DBLTHE-20241203134438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603273
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:44:47 PM

Document Has Been Signed on 12/03/2024 01:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BRADBOURNE		FACILITY NUMBER:	198603273
ADMINISTRATOR/ DIRECTOR:	PEREZ, JOEY		FACILITY TYPE:	735
ADDRESS:	1332 BRADBOURNE		TELEPHONE:	(855) 302-3331
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY: 4		CENSUS: 4	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:08 AM
MET WITH:	Arnejinea Toney - Caregiver, Ashley Balinger, Administrator and Juana Ivett Busby (23 /Fifteen General Manager)		TIME VISIT/ INSPECTION COMPLETED:	01:47 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alberto Lopez conducted the required unannounced annual inspection. LPA met with Arejinea Toney (DSP2) Ashley Ballinger (Administrator) and Juana Ivett Busby (23 /Fifteen General Manager) and explained the reason for the visit. The facility is licensed to serve Four (4) ambulatory (3 of which may be non-ambulatory) clients ages 18-59. Facility currently has three (3) ambulatory and one (1) non-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. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged. Three (3) outside window frames are in need of repair and/or paint.

(Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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 12/03/2024 01:44 PM - It Cannot Be Edited

Created By: Alberto Lopez On 12/03/2024 at 01:29 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Three window frames ouside the home are in need of repair and or paint, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Administrator will repair and/or paint the window frames and send proof to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lisa Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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: 12/03/2024

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Operational Requirements: The facility maintains an approved fire clearance and conduct regular fire/earthquake drills. The last earthquake drill was 09/02/2024 and fire drill 09/03/2024 Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use.

Staffing: There appears to be always sufficient staffing at the facility. Night staff is trained and able to assist in care and supervision of the clients in the case of an emergency. All staff are over 18 years of age.

Personnel Records-Training: Staff files are maintained in a locked cabinet, LPA reviewed 5 staff files during today’s visit, All five (5) staff files had first-aid certificate, all other files reviewed have criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Ashley Ballinger certificate expired on 08/02/2024 Renewal was sent on 07/24/2024 and is pending.

Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides internet and telephone landline for the clients. Client rights poster is on the wall.
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 all medications are given according to doctor’s orders.
Incidental Medical & Dental: Clients are assisted with medical and dental services.

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. Emergency Plan needs to be updated.

Emergency Intervention: Clients at this facility do not have restraints but they require the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiency observed during the visit is documented on 809D. Technical Advisory issued.

Exit interview was held and a copy of the report was provided to Administrator Ashley Ballinger

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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