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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209192
Report Date: 04/17/2025
Date Signed: 04/17/2025 12:59:14 PM

Document Has Been Signed on 04/17/2025 12:59 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BRIGHTON MANORFACILITY NUMBER:
157209192
ADMINISTRATOR/
DIRECTOR:		KAUR, LAKHWINDERFACILITY TYPE:
740
ADDRESS:305 ALUM BAY COURTTELEPHONE:
(661) 589-1500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 4DATE:
04/17/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 4/17/25, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) A. Walton conducted an unannounced Annual Continuation visit to facility. LPM and LPA arrived, introduced themselves, stated purpose of visit, and allowed entrance by Caregiver. Designee, Shontina Kelly, contacted by telephone and arrived a short time later to conduct facility visit.

During last facility visit, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. Prior to today's inspection, LPM Walton received a Administrator packet for Rosanda Anderson that is currently under review.

Upon entry, LPA observed a pin pad on both exterior and interior of door that requires code to unlock front door. . Resident bedrooms toured, residents rooms are observed to have required furnishings, Bedroom #4 observed to have to have a pin pad on both exterior and interior of door that requires a code to unlock door. LPA was unable to open door, bedroom #4 is designated as bedridden bedroom. Resident bathroom toured, water temperature measured at 108 degrees F. Shower/Tub observed to have a non-skid mat and shower chair available. Kitchen toured, LPA observed adequate food supply for residents in care. LPA observed lock on pantry door that needs to be removed. Medication reviewed and observed to be administered as prescribed.

During facility tour, LPA asked designee how residents exited facility, designee stated that they just had to push "letter C" on pin pad and pull door open. R1 was unable to open door when asked by LPA.
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Melinda Medina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BRIGHTON MANOR
FACILITY NUMBER: 157209192
VISIT DATE: 04/17/2025
NARRATIVE
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Staff and resident files reviewed during previous inspection on 3/27/2025. All staff files reviewed are missing proper documentation for training. Resident files were incomplete and did not contain, admission agreements, Appraisal/Needs and Services Plans.

Outside of facility toured. LPA observed door to back patio has a pin pad on the door that requires a code to exit. At time of inspection, LPA was able to exit without a code. LPA observed shaded area with table and chairs but in need of cleaning. LPA observed several gardening tools in the backyard that need to be locked and secured. LPA observed in an operable car and jet ski on trailer that need to be moved. Designated fire exit in back yard exiting to street observed unlocked but has a double sided dead bolt that needs to be removed.

Administrator to submit current copy of Liability insurance, LIC 500, LIC 610, and LIC 9020 to Fresno Regional Office no later than Friday, May, 2, 2025.

All deficiencies observed are being cited on the attached 809-D. Immediate Civil Penalty Assessed.

Exit interview conducted. A copy of report provided to staff for facility records.
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Melinda Medina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/17/2025 12:59 PM - It Cannot Be Edited


Created By: Melinda Medina On 04/17/2025 at 11:56 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BRIGHTON MANOR
FACILITY NUMBER: 157209192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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, LPA observed a pin pad on both exterior and interior of door that requires code to unlock front door, pin pad on interior of door to exit to back yard, and on both exterior and interior of bedroom #3 designated as bedridden. LPA also observed a double sided dead bolt on fire exit from back yard to street that must be removed which is which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Designes stated that pin pad will be removed from all interior doors of facility. 2-sided dead bolt on designated fire exit from backyard to street will be removed.
Type A
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation during facility inspection, the licensee did not comply with the section cited above, R2 and R3 designated as 1:1 in care plan, there was only 1 staff present for four residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Designee to update schedule and have adequate staffing to provide proper care and supervision of residents in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Melinda Medina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/17/2025 12:59 PM - It Cannot Be Edited


Created By: Melinda Medina On 04/17/2025 at 11:56 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BRIGHTON MANOR
FACILITY NUMBER: 157209192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

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 as resident files reviewed did not contain care plans which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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All resident care plans are being updated and will be placed in files.
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 LPA observed gardening tools in the back yard, and an inoperable car and jet ski on trailer that need to be movedi which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Gardening tools to be stored and locked after use. Inoperable care and jet ski on trailer to be moved
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Melinda Medina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/17/2025 12:59 PM - It Cannot Be Edited


Created By: Melinda Medina On 04/17/2025 at 11:56 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BRIGHTON MANOR
FACILITY NUMBER: 157209192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
(b) Each resident's record shall contain at least the following information:

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 review of resident records were incomplete, missing and or missing documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Resident files to be reviewed and ensure that all required documents are in file
Type B
Section Cited
HSC
1569.625(c)
(c) the training shall include, but not limited to, the following:

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 staff files are lacking documentation to show annual required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Staff files to be reviewed and ensure that all staff have required annual training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Melinda Medina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
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