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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602885
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:20:59 PM

Document Has Been Signed on 09/19/2024 02:20 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRADDOCK HOMEFACILITY NUMBER:
198602885
ADMINISTRATOR/
DIRECTOR:		DRUMMOND, MARIAFACILITY TYPE:
740
ADDRESS:12136 BRADDOCK DRIVETELEPHONE:
(310) 902-4893
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: 4CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Facility Manager - Briana SimpsonTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 09/19/2024 at around 10:20 AM, Licensing Program Analysts (LPAs), Enriquez and Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator, Frances Snoddy. LPA explained the purpose of the visit and was accompanied by Direct Support Staff, Artie Sutton inside the facility during this inspection.

This facility is licensed to serve 4 ambulatory adults ages 60 and over.
A total of 4 ambulatory residents are currently residing in this facility.

Licensee paid their Annual Licensing Fees today, 09/19/2024.
Approval #153488
Code #945766

The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms, 2 bathrooms, 1 living room, 1 kitchen/dining/office area, and 1 front patio area with two seats.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/19/2024 02:20 PM - It Cannot Be Edited


Created By: Socorro Leandro On 09/19/2024 at 01:46 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRADDOCK HOME
FACILITY NUMBER: 198602885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in having two closests in disrepair (mirror sliding closet doors not opening properly and difficult to open and close), which poses a potential safety risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee agrees to fix two closests in disrepair (mirror sliding closet doors not opening properly and difficult to open and close). Licensee will email pictures and video recordings of fixed closet doors to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in not having hot water temperature reaching 105 to 120 degree F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee agrees to fix hot water temperature to reach 105 to 120 degrees F. Licensee will email video recording of hot water temeparature reaching 105 to 120 degreees F to Socorro.Leandro@dss.ca.gov.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


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Document Has Been Signed on 09/19/2024 02:20 PM - It Cannot Be Edited


Created By: Socorro Leandro On 09/19/2024 at 01:46 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRADDOCK HOME
FACILITY NUMBER: 198602885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having a videoconferencing device dedicated for resident use, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee agrees to place a videoconferencing device dedicated for resident use. Licensee will take a picture of the videoconferencing device and create a plan on how to use the videoconferencing device for resident use. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRADDOCK HOME
FACILITY NUMBER: 198602885
VISIT DATE: 09/19/2024
NARRATIVE
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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPAs toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPAs observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last drill was conducted on 08/12/2024. First aid kit is fully stocked with manual. There are several fire extinguishers on the premises, and they were last serviced on 06/10/2024. There is no videoconferencing device dedicated for resident use on the premises. There is a landline telephone in the office area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRADDOCK HOME
FACILITY NUMBER: 198602885
VISIT DATE: 09/19/2024
NARRATIVE
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4 out of 4 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly and grab bars were secure. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 91.7 to 91.8 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. LPAs observed two closets in disrepair (mirror sliding closet doors not opening properly).

5 staff records were reviewed, 5 out of 5 staff records had required documentation.

5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

Deficiencies are being cited based on LPAs observation and interviews conducted in accordance with the California Code of Regulations, Title 22. Violations regarding: two closets in disrepair (mirror sliding closet doors not opening properly), no videoconferencing device dedicated for resident use, and hot water temperature not ranging from 105 to 120 degrees Fahrenheit.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Facility Manager, Briana Simpson.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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