197607217-8-1-2022-11-AS-LMOA-CGVSUR-20220801141133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607217
Report Date: 07/28/2022
Date Signed: 08/01/2022 02:11:42 PM

Document Has Been Signed on 08/01/2022 02:11 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BRIGHTWATER GUEST HOME 3		FACILITY NUMBER:	197607217
ADMINISTRATOR:	MARK MENESES		FACILITY TYPE:	740
ADDRESS:	1620 IRIS AVENUE		TELEPHONE:	(310) 533-8060
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 5	DATE:	07/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	JEHNMARIC DEMAFELIX/MARIAN DEMASERO		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/28/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Montoya called the facility, spoke with Area Manager Jehnmaric Demafelix and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with House Manager Marian Demasero and explained the purpose of today’s visit. Area Manager JM Demafelix arrived later and joined the visit. The facility is licensed to operate for six (6) bedridden elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA Montoya toured and inside and outside grounds of the facility with Area Manager Demafelix. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.6 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 7/15/2022. A working telephone remains available. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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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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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHTWATER GUEST HOME 3	FACILITY NUMBER: 197607217
	VISIT DATE: 07/28/2022

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

Advisory Note - Technical Assistance was issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Jehnmaric Demafelix.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC809 (FAS) - (06/04)

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