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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607217
Report Date: 05/24/2023
Date Signed: 05/24/2023 01:20:32 PM


Document Has Been Signed on 05/24/2023 01:20 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:BRIGHTWATER GUEST HOME 3FACILITY NUMBER:
197607217
ADMINISTRATOR:MARK MENESESFACILITY TYPE:
740
ADDRESS:1620 IRIS AVENUETELEPHONE:
(310) 533-8060
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 6DATE:
05/24/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:IRENE FORMENTERATIME COMPLETED:
01:45 PM
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On 5/24/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced Plan of Correction visit for the purpose of reviewing the plan of correction and obtaining signatures for an amended report dated 5/19/2023. LPA was greeted by Caregiver Renel Cabral. Area Manager Irene Formentera arrived later and joined the visit. LPA explained the purpose of the visit.

During today's visit, LPA reviewed and discussed the plan of correction with Formentera. LPA corrected the deficiency, 87465(c)(1), and issued a Letter of Deficiency Citation Clearance.

No deficiencies cited during today's visit. Exit interview conducted with Area Manager Irene Formentera.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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