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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
565801788
Report Date:
03/25/2022
Date Signed:
03/25/2022 02:06:52 PM
Document Has Been Signed on
03/25/2022 02:06 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 II
FACILITY NUMBER:
565801788
ADMINISTRATOR:
CHARISSE BRADLEY
FACILITY TYPE:
740
ADDRESS:
805 ERRINGER ROAD
TELEPHONE:
(805) 404-6516
CITY:
SIMI VALLEY
STATE:
CA
ZIP CODE:
93065
CAPACITY:
6
CENSUS:
4
DATE:
03/25/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
Staff-Rhandy Abad and Administrator-Charisse Bradley
TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff Rhandy Abad at 9:30 a.m. and explained the reason for the visit. Administrator Charrisse Bradley arrived a short time there after.
The LPA toured the physical plant areas inside and outside with Rhandy Abad at 9:45 a.m., to ensure there are no health and safety hazards.
BEDROOMS:
The LPA observed five (5) resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. A staff bed was observed in the dining room area that has now been converted to an office/staff room. The facility sketch reflects the staff room as bedroom #1 which is now a resident room. The administrator was advised to notify the department when making any changes to the facility sketch and provide a new plan of operation and new facility sketch with the changes.
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. Restroom hot water measured 110.5 Fahrenheit at 10:30 a.m.
Continued on LIC 809-C
SUPERVISORS NAME
:
Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME
:
Elsie Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
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
11
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
VISIT DATE:
03/25/2022
NARRATIVE
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KITCHEN/FOOD SERVICE AREA:
Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:50 a.m. the LPA observed an unlocked kitchen drawer containing kitchen knives and sharps. Hot water measured 111.5 Fahrenheit at 9:53 a.m. At 10:07 a.m. expired cooking spices were observed on the kitchen counter. At 10:11 a.m. expired canned goods were observed in the dining room pantry, refried beans, sauerkraut, staff disposed of the expired items. The Administrator was advised that a full audit of canned goods and spices needed to be conducted and all expired items are to be thrown out.
COMMON SPACES/GARAGE:
In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. However, did not observe the required provider information notices (PIN) posted upon entry regarding visitation. The LPA observed a screened fireplace in the living room. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The smoke detectors and carbon monoxide detector were tested between 10:24 a.m. - 10:25 a.m. and were operational. The fire extinguisher was observed to be full and last bought on 1/2022. At 9:54 a.m., the laundry area/garage was unlocked, and there were accessible laundry supplies and chemicals. A refrigerator inside the garage contained a unlocked medications and a cabinet with accessible over the counter medications was also observed. Staff secured garage at the time of observation. The garage contains additional perishable food items.
BACKYARD
:
The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.
Continued on LIC 809-C
SUPERVISORS NAME
:
Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME
:
Elsie Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
LIC809
(FAS) - (06/04)
Page:
2
of
11
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
VISIT DATE:
03/25/2022
NARRATIVE
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INFECTION CONTROL:
During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. However, staff were not adhering to sign in policy. The LPA reminded the Administrator that sign in policy is still in effect. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed from the Regional Office upon request. Upon arrival the LPA observed staff not wearing face masks. Staff were reminded that face masks are required at all times and complied at the time of observation. The Administrator was reminded that masking is still required by all staff live in or not and to ensure that all staff are reminded of this policy. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.
The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights were provided via Email.
SUPERVISORS NAME
:
Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME
:
Elsie Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
LIC809
(FAS) - (06/04)
Page:
11
of
11
Document Has Been Signed on
03/25/2022 02:06 PM
- It Cannot Be Edited
Created By:
Elsie Campos
On
03/25/2022
at
12:53 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 II
FACILITY NUMBER:
565801788
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above as two (2) staff upon arrival who were providng care and supervision to residents were observed without a face mask which poses an immediate health and safety risk to
persons in care.
POC Due Date:
03/25/2022
Plan of Correction
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2
3
4
Administrator agreed to the following:
1. To remind staff of masking guidlines and ensure that they wear their face masks at all times no later than 3/25/2022. Plan of correction met at time of the visit.
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above, as S1 has not been associated to the facility, which poses an immediate health and safety risk to residents in care..
POC Due Date:
03/25/2022
Plan of Correction
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2
3
4
Administrator agreed to do the following:
1. Submit association paperwork to CCL no later than 3/25/2022. Plan of correction met at time of the visit.
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:
Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
03/25/2022 02:06 PM
- It Cannot Be Edited
Created By:
Elsie Campos
On
03/25/2022
at
12:53 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 II
FACILITY NUMBER:
565801788
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as expired canned food was observed in the dining room pantry and expired cooking spices were observed on the kitchen counter, which poses a potential health and safety risk to persons in care.
POC Due Date:
03/28/2022
Plan of Correction
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2
3
4
The administrator agreed to do the following:
1. Audit all non perishable and perishable food and ensure all expired canned food, spices and pershiables are discarded.
2. The Administrator will notify CCL of food audit completion no later than 3/28/22.
Type A
Section Cited
CCR
87705(f)(1)
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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2
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4
Based on observation, the licensee failed to ensure that kitchen knives were inaccessible. During the physical plant tour, the LPA observed an unsecured drawer in the kitchen containing knives. This poses an immediate health and safety risk to residents in care.
POC Due Date:
03/25/2022
Plan of Correction
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2
3
4
The Administrator has agreed to do the following:
1) Secure the drawer and ensure that it remains locked at all times. Plan of correction met at time of visit.
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:
Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
03/25/2022 02:06 PM
- It Cannot Be Edited
Created By:
Elsie Campos
On
03/25/2022
at
12:53 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 II
FACILITY NUMBER:
565801788
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as cleaning supplies and over the counter medications were accessible through the unlcoked garage which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/25/2022
Plan of Correction
1
2
3
4
Staff secured the garage at the time of the visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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 Pfannenstiel
LICENSING EVALUATOR NAME:
Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
03/25/2022 02:06 PM
- It Cannot Be Edited
Created By:
Elsie Campos
On
03/25/2022
at
12:53 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 II
FACILITY NUMBER:
565801788
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/25/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87208(a)(7)
Plan of Operation. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing for approval. The plan and related materials shall contain the following: sketches, showing dimensions.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and records review, the licensee failed to inform Licensing about the changes within the facility layout, which poses a potential health and safety risk to residents in care.
POC Due Date:
04/08/2022
Plan of Correction
1
2
3
4
The Administrator has agreed to do the following:
1. Submit a Plan of Action, describing how the licensee will keep the department up to date on all changes
2. Submit an updated facility sketch, with an LIC200
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:
Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE:
03/25/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/25/2022
LIC809
(FAS) - (06/04)
Page:
6
of
11