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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801788
Report Date: 04/27/2023
Date Signed: 04/27/2023 03:48:31 PM


Document Has Been Signed on 04/27/2023 03:48 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 HOUSE IIFACILITY NUMBER:
565801788
ADMINISTRATOR:CHARISSE BRADLEYFACILITY TYPE:
740
ADDRESS:805 ERRINGER ROADTELEPHONE:
(805) 404-6516
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 6DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rhandy AbadTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required Annual visit. The LPA met with Staff Rhandy Abad. Administrator Charisse Bradley was contacted however could not make it to the facility and informed staff to assist LPA during the annual visit. LPA toured the physical plant areas inside and outside with staff between 10:30am-11:30a.m. BEDROOMS: The LPA observed five (5) resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. KITCHEN/FOOD SERVICE AREA: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON SPACES/GARAGE: In the common areas, living room and dining room area and furniture was observed to be in good condition. LPA observed required postings in the hallway. The fireplace in the living room observed with screen. Smoke and carbon monoxide detectors tested and found to be operational during visit. Fire extinguisher was observed to be full charged. Laundry area/garage was observed locked during visit. Staff unlocked the garage at the time of visit. The garage contains cleaning supplies, laundry detergent and additional refrigerator with perishable food items. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Supply of Personal Protection Equipment (PPE) observed sufficient at the time of visit. The following deficiencies were observed and cited from the California Code of Regulations, Title 22 and California Health and Safety Code:
Staff are sleeping in the common living area - Approximately 10:45am - bed observed in the office space; staff reported sleeping in the office space/common area. At approximately 11:18am a folding bed was observed in the backyard; staff reported this folding bed is used by the other staff at night in the living room.
Discussion held at great length regarding this violation with staff. At approximately 11:33am LPA noticed that the sliding door in the living/dining is very difficult to open and close; handle is broken on the outside and handle inside is lose with screw sticking out. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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 04/27/2023 03:48 PM - It Cannot Be Edited

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 II
FACILITY NUMBER: 565801788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with staff, the licensee did not comply with the section cited above as a section of the common living area was used as a staff sleeping area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Staff shall inform Administrator of the above and Administrator shall provide updated staff schedule to reflect 24 hour care services due to not having a designated staff room. Also remove mattresses and any bed like items from the office/common area. Provide photo of cleared room. Plan of correction due 4/28/2023.
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.
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. Sliding door in living/dining area observed not opening and closing properly; much force is needed to open and close door; also sliding door handle from inside is not in good repair and the outside handle is broken. This poses safety risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator shall have the sliding door repaired to open and close properly with properly installed handles.
Provide proof of service completed and include photos. Plan of correction due by 5/4/2023.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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