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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607217
Report Date: 05/16/2026
Date Signed: 05/16/2026 04:54:49 PM

Document Has Been Signed on 05/16/2026 04:54 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRIGHTWATER GUEST HOME 3FACILITY NUMBER:
197607217
ADMINISTRATOR/
DIRECTOR:		IRENE FORMENTERAFACILITY TYPE:
740
ADDRESS:1620 IRIS AVENUETELEPHONE:
(310) 533-8060
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 6DATE:
05/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Irene FormenteraTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 05/16/2026, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced annual inspection visit and met with the Administrator, Irene Formentera. The purpose of the visit was explained and the LPA was allowed entry to the facility.

This facility is licensed to serve 6 bedridden adults ages 60 and above. 5 bedrooms are cleared for bedridden residents. The facility is approved to admit or retain 2 residents on hospice.

A total of 6 residents are currently residing in this facility.

The LIC999 Facility Sketch (Floor Plan) that is on file in El Segundo Regional Office depicts the following: a one-story house with 5 resident bedrooms, 1 staff room, 3 bathrooms, 1 attached garage, and a great room with kitchen and living room.

Facility Layout (LPA Observations): is a one-story house located in a residential street. The home consists of 6 resident bedrooms (resident bedroom 6 is designated as the staff in the LIC999); 3 full bathrooms; 1 staff room walls are not touching the ceiling (this room is not depicted on the LIC999); 1 great room which includes the kitchen area, dining table, and living room area; 1 attached garage; and 1 backyard patio area with shaded seating.

Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2026
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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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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Document Has Been Signed on 05/16/2026 04:54 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/16/2026 at 03:53 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHTWATER GUEST HOME 3
FACILITY NUMBER: 197607217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having a leaky shower faucet in bathroom 1; the garage has several items which makes it difficult to maneuver around or grab items; room 1 has a non-ambulatory resident who uses a wheelchair and their room has several items on the floor which makes it difficult to maneuver around, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2026
Plan of Correction
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The Administrator has agreed to fix bathroom 1's shower faucet; declutter the garage; declutter Room 1 and make it a safe and comfortable place for the resident. The Administrator will email pictures to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in the hot water temperature measuring 129.02 Fahrenheit.
POC Due Date: 05/17/2026
Plan of Correction
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The Administrator will fix hot water temperature to measure 105 to 120 degrees Fahrenheit. The Administrator has agreed to create a plan to maintain hot water temperatures at 105 to 120 degrees Fahrenheit.

Email proof of correction to: Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2026 04:54 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/16/2026 at 03:53 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHTWATER GUEST HOME 3
FACILITY NUMBER: 197607217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not their facility layout not matching their facility sketch (there is a staff room that was not on the facility sketch), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2026
Plan of Correction
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The Administrator agreed to update the facility sketch and email it to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having updated records for Resident 2 (does not have an updated Medical Assessment & does not have their Home Health Folder), Resident 4 (does not have doctors order for half bed rail), and Resident 5 (does not have an updated Medical Assessment), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Administrator has agreed to update Resident 2, Resident 4 and Resident 5's file and email records to Socorro.Leandro@dss.ca.gov The licensee has agreed to create a plan to maintain complete and current records in the facility for each resident and email plan to Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2026


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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRIGHTWATER GUEST HOME 3
FACILITY NUMBER: 197607217
VISIT DATE: 05/16/2026
NARRATIVE
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Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher near the kitchen area. There is a landline phone in the kitchen area.

Living Room/Community Indoor Space: There is a videoconferencing device, and games/activity work for residents in the living room area. There are couches and chairs for residents to sit at.

Resident Bedrooms: 6 out of 6 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Room 1 has a non-ambulatory resident who uses a wheelchair and their room has several items on the floor which makes it difficult to maneuver around

Bathrooms: Toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. The hot water temperature measured 129.2 Fahrenheit. There was a leaky shower faucet in bathroom 1.

Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Medications were reviewed along with their Administration Records (MARs).

Garage: has several items which makes it difficult to maneuver around.

Miscellaneous: Documents are posted as mandated. Last disaster drill was conducted on 04/15/2026. The last Annual Fire Inspection was completed by the Torrance Fire Department on 04/14/2026. First aid kit is fully stocked with manual. Liability Insurance is current and it expires on 11/01/2026. The facility has a current Infection Control Plan and Emergency Disaster Drill.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRIGHTWATER GUEST HOME 3
FACILITY NUMBER: 197607217
VISIT DATE: 05/16/2026
NARRATIVE
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5 resident records were reviewed, 3 out of 5 resident records did not have requires documentation. Resident 2 does not have an updated Medical Assessment and does not have their Home Health Folder. Resident 4 does not have doctors order for half bed rail. Resident 5 does not have an updated Medical Assessment.

Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026
LIC809 (FAS) - (06/04)
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