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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800622
Report Date: 02/09/2022
Date Signed: 02/10/2022 08:14:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A BRADLEY HOUSEFACILITY NUMBER:
565800622
ADMINISTRATOR:CHARISSE BRADLEYFACILITY TYPE:
740
ADDRESS:4031 APRICOT ROADTELEPHONE:
(805) 578-1933
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Charisse BradleyTIME COMPLETED:
05:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 01:52 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee Charisse Bradley and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged.

KITCHEN: Knives were found in an unlocked drawer and cleaning supplies were found in an unlocked cabinet. Laundry detergent was observed in an unlocked room off the kitchen. Pre-poured medications were observed on the kitchen counter. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All other medications were stored in a locked cabinet.

BEDROOMS: The LPA observed four single-occupancy resident bedrooms and one shared bedroom which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restrooms are clean and sanitary and in operating condition. LPA observed bathroom cleaner in an unlocked cabinet.

COMMON SPACES: The living room, family room and dining room furniture were observed to be in good condition. The front yard is gated, has a patio area, and is equipped with furniture for resident use.

continued on 809-C

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A BRADLEY HOUSE
FACILITY NUMBER: 565800622
VISIT DATE: 02/09/2022
NARRATIVE
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continued from 809

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Staff was not wearing a mask upon LPA's entry. Infection control postings were observed. The facility had an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).


Exit interview conducted. Today's reports and appeal rights were discussed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BRADLEY HOUSE
FACILITY NUMBER: 565800622
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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. LPA observed pre-poured medications were left out on the counter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Staff moved the medications to a locked cabinet. Administrator will provide evidence of staff training on securing medications to CCL on or before 2/16/22.
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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. LPA observed knives stored in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Staff moved the knives to a locked cabinet. Administrator will provide evidence of training staff on securing items dangerous to residents to CCL on or before 02/16/22.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BRADLEY HOUSE
FACILITY NUMBER: 565800622
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)

87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. LPA observed cleaning supplies stored in unlocked cabinets in the bathroom and kitchen as well as the laundry area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Staff secured cleaning supplies in a locked cabinet. Administrator will provide evidence of staff training regarding securing dangerous substances to CCL on or before 02/16/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BRADLEY HOUSE
FACILITY NUMBER: 565800622
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations.

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. LPA observed both staff at the facility were not wearing face coverings while providing resident care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Administerator will provide evidence of staff training on Infection Control Practices (PIN 21-38-ASC) regarding wearing masks in the facility to CCL by 02/16/22.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5