<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202698
Report Date: 06/27/2022
Date Signed: 06/28/2022 08:57:44 AM

Document Has Been Signed on 06/28/2022 08:57 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,
, CA
FACILITY NAME:BRIDGE HOUSEFACILITY NUMBER:
275202698
ADMINISTRATOR:MARISOL GUTIERREZ-ALVAREZFACILITY TYPE:
772
ADDRESS:601/603 BAYONET CIRCLETELEPHONE:
(831) 647-3000
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 14CENSUS: 10DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer Gilmore and Miriam Gonzalez-GomezTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature are maintained and average at 118.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are operational. During the tour of the facility LPA and Staff observed unlocked cleaning supplies/toxins in the residents bathroom, Staff removed the toxins during the inspection.

LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed R1 has not started the order for diabetic testing. R1 moved into the facility on 6/21/2022 the facility has not started checking R1's sugar levels. LPA and Staff also discovered that R2 has an order from the doctor to administer their own medication, R2 medication count was off for one medication reviewed due to no start date listed in the centrally stored log or on the medication sheet.

LPA reviewed 7 resident and 5 staff files, including criminal record clearances. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Fire drill and other drills conducted as required.
Per the Title 22, Division 6 of California Code of Regulations, deficiencies were observed during today's inspection and cited on the attached 809 D page.

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/28/2022 08:57 AM - It Cannot Be Edited


Created By: Albert Johnson On 06/27/2022 at 03:04 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
,
, CA

FACILITY NAME: BRIDGE HOUSE
FACILITY NUMBER: 275202698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2022
Section Cited
CCR
81087(l)

1
2
3
4
5
6
7
(l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions, and poisons are stored where inaccessible to clients.
1
2
3
4
5
6
7
Staff removed the items and locked them away during the inspection.

Administrator shall ensure that all toxins are kept locked and inaccessible to residents in care at all times.
8
9
10
11
12
13
14
This requirement was not met as evidenced by observation during the tour of the facility. This is an immediate health and safety issues for residents in care.
8
9
10
11
12
13
14
 In-service training is required for staff. Proof of correction such as staff training record to be sent to albert.johnson@dss.ca.gov by the date indicated.
Type A
06/28/2022
Section Cited
CCR81092.8

1
2
3
4
5
6
7
(a) A licensee may admit or retain a client who has diabetes if all of the following conditions are met:(1) The licensee is in compliance with Section 81092.1.
1
2
3
4
5
6
7
All staff that handle medication shall attend an inservice training to ensure that medications are given correctly and records are kept current and accurate. Administrator shall submit medication training schedule
8
9
10
11
12
13
14
(2) The client is mentally and physically capable of administering his/her own medication and performing his/her own glucose testing if applicable, or a licensed professional administers the tests and injections. This requirements was not met as evidenced by the lack of testing kit and records for R1. This is an immediate health and safety issues for residents in care.
8
9
10
11
12
13
14
and trainer information to CCL by POC date. (Medication training must be completed within 7 days).
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2