197607217-5-5-2023-11-AS-MVAO-CTHTKF-20230707144753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607217
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:16:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20230503123613

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: 6	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	JM DEMAFELIX		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not notify Licensing of an incident.

INVESTIGATION FINDINGS:

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On 5/5/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced 10-day complaint visit at this facility to obtain information about the allegation above. LPA was greeted by Caregivers Mardie Rodriguez and Rogelio Matic. Chief Executive Officer (CEO) William Gallos, Chief Operations Officer (COO) JM Demafelix and Area Manager Irene Formentera arrived later and joined the visit. LPA explained the purpose of the visit. Demafelix assisted LPA with the visit.

The investigation consists of the following: LPA obtained copies of the facility roster for residents and staff. Interviews were conducted with four staff (S1-S4). LPA obtained R1's service records and a copy of an incident report for R1. A tour of the facility was conducted.

REPORT CONTINUED IN LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230503123613

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/05/2023

NARRATIVE

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INVESTIGATIONS REVEALED:

Regarding Allegation: Staff did not notify Licensing of an incident.

It was reported that staff failed to notify Licensing of an incident that occurred on 4/28/23 or 4/29/2023 on a resident (R1). Based on LPA's record review, the facility reported an incident on R1's unusual incident that occurred on 4/29/2023. A copy of fax transmittal (or called Communication Management Report) shows three pages were sent to CCLD's fax number 323-981-1781 at 5/1/2023 at the hour of 17:13. The result shows the transaction was successfully sent and received by CCLD. Based on gathered information, there is no sufficient evidence to corroborate the above allegation.

Based on information gathered, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegation is Unsubstantiated.

An exit interview was conducted with COO JM Demafelix and a copy of the report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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