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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607217
Report Date: 06/16/2023
Date Signed: 06/16/2023 03:54:44 PM


Document Has Been Signed on 06/16/2023 03:54 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, 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:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Facility manager Renel CabralTIME COMPLETED:
12:00 PM
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On 06/16/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Renel Cabral and later joined by Administrator Mark Meneses as the purpose of today’s visit was explained. The facility is licensed to serve elderly residents age 60 and above. All five (5) rooms are cleared for bedridden fire clearance. Facility is cleared for six (6) bedridden residents and the facility is approved to admit or retain two (2) residents on hospice. The facility is 87705 compliant.

The facility is a single-story structure located in a residential neighborhood and consists of the following: six (6) resident bedrooms, one (1) staff rest/break room, three (3) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA conducted a records review of one (1) staff records, two (2) resident records and two (2) Medication Administration Records, LPA did not observe any discrepancies at the time of visit. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 05/02/23, three (3) fire extinguishers fully charged, carbon monoxide detectors and smoke detectors interconnected are working properly. Landline was observed.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, all grab bars were securely attached, and all showers had a non-skid mat and there is sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRIGHTWATER GUEST HOME 3
FACILITY NUMBER: 197607217
VISIT DATE: 06/16/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancies were observed.

Exit interview conducted with Administrator Mark Meneses, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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