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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200112
Report Date: 08/16/2021
Date Signed: 08/16/2021 05:53:24 PM

Document Has Been Signed on 08/16/2021 05:53 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BRIGHT STAR RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
019200112
ADMINISTRATOR:RONDIE M. WAUGHFACILITY TYPE:
735
ADDRESS:8939 LAWLOR STREETTELEPHONE:
(510) 636-0887
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 6DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Rondie Waugh, Administrator
Patrice Waugh, House Supervisor		TIME COMPLETED:
06:10 PM
NARRATIVE
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On 8/16/2021 at 3:35PM, Licensing Program Analysts (LPAs) G. Luk and G. Clark arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Rondie Waugh and explained the purpose of the visit.

Upon arrival, LPAs temperatures were checked. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, living room, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitor logs and temperature logs for both clients and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 4:00PM, LPAs observed food supplies were stored with cleaning supplies. Administrator removed cleaning supplies and stored them separate from food supplies.
-At 4:10PM, LPAs observed facility did not have a carbon monoxide detector in common area.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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 08/16/2021 05:53 PM - It Cannot Be Edited


Created By: Grace Luk On 08/16/2021 at 05:43 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRIGHT STAR RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 019200112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 by not having one or more carbon monoxide detectors in the common areas which poses a potential health and safety risk to persons in care.
POC Due Date: 08/20/2021
Plan of Correction
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Administrator will purchase a carbon monoxide detector and put it in the common area. Administrator will submit purchase receipt and picture of the carbon monoxide detector after installation to CCLD by POC date.
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 by storing cleaning supplies with food items which poses a potential health and safety risk to persons in care.
POC Due Date: 08/17/2021
Plan of Correction
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Administrator removed the cleaning supplies and stored it in a separate area during inspection.

Deficiency cleared during inspection.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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