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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801788
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:23:25 PM

Document Has Been Signed on 04/25/2024 03:23 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/
DIRECTOR:		CHARISSE BRADLEYFACILITY TYPE:
740
ADDRESS:805 ERRINGER ROADTELEPHONE:
(805) 404-6516
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Rhandy AbadTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required Annual inspection today. Upon arrival, there were two (2) staff members and six (6) residents present. The LPA was greeted at the door by staff, Marilyn Ino and Rhandy Abad. Staff contacted the Administrator, Charisse Bradley telephonically and the reason for the visit was explained. The Administrator informed the LPA that staff was able to assist and sign report. Entrance interview conducted.

At 8:48 a.m., the LPA along with the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 8:49 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and pantry were checked for proper labels and expiration dates. Knives and sharps were observed in a locked drawer inaccessible to residents at the time of the visit. At 8:56 a.m., the hot water was measured in the kitchen sink at it measured 116.4 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 9:14 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational. The fire extinguisher was observed with a purchase date of 05/09/2023.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A BRADLEY HOUSE II
FACILITY NUMBER: 565801788
VISIT DATE: 04/25/2024
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Continued from LIC 809...

The LPA observed required postings throughout the common space. There is a working telephone on premises. An adequate supply of emergency food and water was observed at the time of the visit.

GARAGE: The garage was observed inaccessible to residents at the time of the visit. The washer and dryer were observed inside the garage. There was an additional refrigerator and freezer observed with perishable foods in good condition. Detergents and toxins were observed inaccessible to residents at the time of the visit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There are two (2) gates that self-latch. No bodies of water were noted at the time of the visit.

BEDROOMS: There are five (5) resident bedrooms. One (1) bedroom is double occupancy, and four (4) bedrooms are for single occupancy. LPA observed the resident bedrooms to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. There is a cabinet in the hallway with additional clean linens and towels.

RESTROOMS: There are two (2) resident restrooms. Restrooms were observed with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms, and they measured between 105- and 120-degrees Fahrenheit at the time of the visit.

RECORDS: Records review began at 9:26 a.m.; six (6) resident records were reviewed for, but not limited to: : signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan.

During file review, LPA observed five (5) out of six (6) resident admissions agreement to be missing licensee/administrator signature and date. Staff stated administrator will be coming in to sign and date admissions agreement.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A BRADLEY HOUSE II
FACILITY NUMBER: 565801788
VISIT DATE: 04/25/2024
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Continued from LIC 809C...

Two (2) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Files were complete.

LPA was unable to review current Administrator’s file as it was not available during the inspection. Staff stated Administrator will email copy of file to LPA.

The last emergency disaster drill was conducted on 01/15/2024.

LPA interviewed two (2) staff members during the inspection.

MEDICATIONS: Medications review began at approximately 12:25 p.m.; medications are centrally stored in a locked cabinet adjacent to the kitchen.

At 12:55 p.m., medication review revealed that two (2) out of six (6) residents centrally stored medication and destruction record (CSMDR) are not being filled out with correct start dates as the quantity of pills left in the bottle do not match with the quantity resulting from start date on record. Staff stated they will audit medications and CSMDR and fill out with correct information.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. Report was reviewed with staff and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 03:23 PM - It Cannot Be Edited


Created By: Martha Arroyo On 04/25/2024 at 02:46 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BRADLEY HOUSE II
FACILITY NUMBER: 565801788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and LPA observation, the licensee did not comply with the section cited above as the Administrator's file was not available during the inspection, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Staff stated the Administrator well email copy of Administrator's fille to LPA by poc due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and LPA observation, the licensee did not comply with the section cited above as five (5) out of six (6) residents admissions agreement were missing the Administrator's signature and date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Staff stated Administrator will sign and date admissions agreement and send proof to LPA 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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


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