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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603692
Report Date: 01/29/2024
Date Signed: 01/29/2024 05:09:23 PM

Document Has Been Signed on 01/29/2024 05:09 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BRADFORD RESIDENTIAL CARE INC.FACILITY NUMBER:
198603692
ADMINISTRATOR:SANTAMARIA, HUMBERTOFACILITY TYPE:
740
ADDRESS:1111 BRADFORD DRIVETELEPHONE:
(626) 233-7489
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 3DATE:
01/29/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Humberto Santamaria- Licensee/AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required Post-Licensing inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Licensee/Administrator, Humberto Santamaria, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Licensee, observed the facility food supplies, reviewed (3) resident medications, (3) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (3) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently no residents receiving hospice services. An Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file.
Upon entry, LPA Maldonado observed a video screen on the kitchen counter with audio, projecting a live video feed of Resident#2's (R2) room with R2 and their visitors in the room. LPA inquired with Licensee on the surveillance camera, who stated that R2's family brought it and requested it be used to keep view of R2 due to R2 wandering at night. Licensee stated however, that they have not had any issues with R2 wandering or getting up at night since admission to the facility.
LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. LPA observed full bed rails on Resident#1-2's beds, which have written orders from the use of them. The resident bathroom is equipped with required grab bars and non-skid mats. The hot water was tested and measured at 119*F, which is in compliance. Food supplies was observed and was sufficient as required. There are no bodies of water on the premises. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents.
(Report Continued on LIC809-D...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BRADFORD RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603692
VISIT DATE: 01/29/2024
NARRATIVE
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Smoke/carbon monoxide detectors were observed in each room- last fire drill conducted on 1/08/24. Auditory devices were observed at all entrances/exits of the home and operational. (3) resident files and (3) staff files were reviewed. (3) Resident files were observed to be missing signatures by residents or their responsible parties on Physician's Reports, Appraisal/Needs and Services Plans, Resident Inventory documents, and Consent for Emergency Medical Treatment forms were incomplete. (1) Resident file was missing a Pre-Placement Appraisal. (1) Staff file was observed to be missing a Health Screening, and (2) staff records were missing training records. At 3:00PM, LPA reviewed (3) resident medications, and discovered records for Centrally Stored Medications to be missing for several medications. LPA could not determine that all medications are given as prescribed.

Per California Code of Regulations, Title 22, citations will be cited on the LIC809-D page.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 01/29/2024 05:09 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 01/29/2024 at 04:41 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADFORD RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603692

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 of 3 residents using a video surveillence camera without a waiver or permission from the licensing agency, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will submit a writen request for a waiver for the use of the surveillance camera for the resident, as indicated in their admission agreement, as well as an updated Plan of Operations.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/29/2024 05:09 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 01/29/2024 at 04:55 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADFORD RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603692

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 4 staff missing a health screening on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will complete and submit a health screening for 1 staff and submit to LPA via email by POC due date.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 4 staff missing training records in their files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will obtain training records for 2 staff and submit them to LPA via email by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/29/2024 05:09 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 01/29/2024 at 04:55 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRADFORD RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603692

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 od 4 residents missing records of personal property, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will complete and submit 1 resident's Personal property records to LPA via email by the POC due date.
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 4 residents missing a Pre-Admission appraisal in their file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will complete Pre-Admission Appraisal for 1 resident and submit to LPA via email by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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