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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800622
Report Date: 11/03/2021
Date Signed: 11/03/2021 04:57:15 PM

Document Has Been Signed on 11/03/2021 04:57 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
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: 6DATE:
11/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Charisse BradleyTIME COMPLETED:
03:40 PM
NARRATIVE
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This Case Management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20211102161023 investigation visit conducted on 11/03/21.

While reviewing records for resident #1 (R1) it was observed the records lacked a physicians report and a pre-placement appraisal.

While meeting with staff #1 (S1) and reviewing S1's records at 01:54 p.m., it was noted S1 has a criminal background clearance but S1's criminal clearance record is not associated to this facility.

Exit interview conducted with Administrator Charisse Bradley, report was signed by S1. Report emailed to the Administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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 11/03/2021 04:57 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/03/2021 at 02:56 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BRADLEY HOUSE
FACILITY NUMBER: 565800622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2021
Section Cited
CCR
87355(c)

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87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer
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 Administrator will complete an LIC9182 and email the document along with a copy of S1's driver's license to CCLD on or before 11/04/21.
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Request, LIC 9182 (Rev. 4/02). (2) A copy of the individual's: (A) Driver's license, or...

S1 is not associated with this facility. LPA confirmed S1 has a criminal record clearance and is associated to other facilities but needs to be associated to this facility.
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Type B
11/10/2021
Section Cited
CCR87457(c)(1)

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87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
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Administrator will complete an LIC603 preplacement appraisal and send a copy to CCLD on or before 11/10/21.
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(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors
R1 does not have a preplacement appraisal on file.
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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 Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 11/03/2021 04:57 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/03/2021 at 03:12 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BRADLEY HOUSE
FACILITY NUMBER: 565800622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2021
Section Cited
CCR
87458(a)

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Administrator will obtain a completed Physician's Report from R1's physician and send a copy to CCLD on or before 11/10/21.
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R1 does not have a physician's report on file at the facility.
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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 Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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