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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603273
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:30:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2021 and conducted by Evaluator Elizabeth Ceniceros
COMPLAINT CONTROL NUMBER: 28-AS-20210330100524
FACILITY NAME:BRADBOURNEFACILITY NUMBER:
198603273
ADMINISTRATOR:SMITH, JAYFACILITY TYPE:
735
ADDRESS:1332 BRADBOURNETELEPHONE:
(855) 302-3331
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:4CENSUS: 4DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Joey PerezTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Clients sustained injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A2: Joey Perez). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 04/07/21 (via telephone) with Licensee/Administrator (A1: Jay Smith) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA conducted interviews (between 2:00 p.m. - 3:30 p.m. (via landline) with Licensee (Jay Smith), Staff #2 (Arejinae Toney), and Staff #3 (Ashley Ballinger); and in person with Administrator (Joey Perez) and Staff #1 (Yvette Busby, General Manager). LPA/RA did not interview Client #1 or Client #2 as the the facility served as a regional office Surge (Respid) Home caring for COVID-19
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20210330100524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2022
NARRATIVE
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clients on a short-term basis (10-15 days). LPA/RA did not review records for Client #1 or Client #2 as they returned to their adult residential facility home after 10-days of isolation.

Regarding Allegation #1: this investigation revealed that the facility served as a Surge Home for the regional center during the Coronavirus Disease 2019 (COVID-19). Client #1 arrived to the facility on 02/04/21 and returned to its home on 02/15/21. Interviews were conducted of facility staff; and, the majority indicated that when Client #1 arrived to the Surge Home, the client came without a cane or wheelchair. Facility staff noticed that Client #1 appeared to have scratched-up knees; but, as time went on, Client #1 would refuse to lay on its bed and preferred crawling on the floor; therefore, staff would have to lay down blankets on the floor for the client. S1 indicated that the facility purchased a wheelchair for Client #1; however, the client could not sit in the wheelchair and preferred crawling around on the floor. When staff would put Client #1 to bed, the client would jump from its bed onto the floor and land on both knees. Client #2 arrived to the facility on 02/04/21 and returned to its home on 02/15/21. Interviews were conducted of facility staff; and, the majority indicated that Client #2 had a blister like on its upper right arm, but no bruising or wounds. Staff indicated that the clients would receive a sponge bath during the P.M. shift and staff would have noticed if clients sustained serious injuries to its person; although, the facility served as a Surge Home for COVID-19.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Clients sustained injuries while in care is found to be UNSUBSTANTIATED.

An exit interview was conducted and a copy of the Complaint Report provided to Administrator (Joey Perez).

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2