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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607217
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:45:33 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
05/02/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230502112913
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:
05/19/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:IRENE FORMENTERATIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained injury due to staff handling resident in a rough manner.
INVESTIGATION FINDINGS:
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On 5/19/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain information about the allegation above and to deliver a complaint finding. LPA was greeted by Caregiver Renel Cabral. Area Manager Irene Formentera arrived later and joined the visit. LPA explained the purpose of the visit.

The investigation consists of the following: On 5/5/2023, LPA obtained copies of the facility roster for residents and staff. Interviews were conducted with four staff (S1-S4), one resident (R1) and one witness (W1). LPA obtained R1's service records. A tour of the facility was conducted. On 5/19/2023, LPA interviewed two residents (R2-R3) during the visit. LPA interviewed two staff (S5 and S6) and a witness (W2) via telephone. LPA obtained copies of R1's Medication Administration Records (MAR) for February 2023 thru April 2023. LPA's attempt to interview three residents (R4-R6) was unsuccessful due to the residents' medical conditions.

Report continued in LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 11-AS-20230502112913
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: 05/19/2023
NARRATIVE
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Investigations revealed:

Regarding allegation: Resident sustained injury due to staff handling resident in a rough manner.

It was alleged that resident sustained a skin tear on right arm about 2-3 inches long on 4/29/2023. Based on the Department’s records review, R1 was admitted to the facility on 2/8/2023. R1 is diagnosed with a dementia. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Six staff (S1-S6), two residents (R2-R3) denied that R1 sustained injury due to staff handling resident in a rough manner. R1 claimed S6 grabbed R1’s arm roughly and verbally threatened R1. S5 stated R1 was noticed with a skin tear after a routine diaper change. S5 stated two staff (S5 and S6) assisted R1 with diaper change to provide extra care for R1’s fragile skin. S5 stated the cause of R1’s skin tear is unknown and unnoticed. During interview with S6, the department observed S6 was stuttering and had difficulty speaking. S5 informed the department that S6 has a difficulty in speech but S6 is able to perform the assigned tasks. W1 and W2 revealed R1 has sensitive and fragile skin and R1 had prior skin tear on right forearm in a different facility. W2 stated R1 sustains bruises due to medications and skin condition. Based on gathered information, there is no sufficient evidence that resident sustained injury due to staff handling resident in a rough manner.

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 Area Manager Irene Formentera and a copy of the report was provided.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
05/02/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230502112913

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:
05/19/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:IRENE FORMENTERATIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not notify resident's authorized representative of incident.
Staff did not properly care for resident's wound.
INVESTIGATION FINDINGS:
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On 5/19/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain information about the allegation above and to deliver complaint finding. LPA was greeted by Caregiver Renel Cabral. Area Manager Irene Formentera arrived later and joined the visit. LPA explained the purpose of the visit.

The investigation consists of the following: On 5/5/2023, LPA obtained copies of the facility roster for residents and staff. Interviews were conducted with four staff (S1-S4), one resident (R1) and one witness (W1). LPA obtained R1's service records. A tour of the facility was conducted. On 5/19/2023, LPA interviewed two residents (R2-R3) during the visit. LPA interviewed two staff (S5 and S6) and a witness (W2) via telephone. LPA obtained copies of R1's Medication Administration Records (MAR) for February 2023 thru April 2023. LPA's attempt to interview three residents (R4-R6) was unsuccessful due to the residents' medical conditions.

Report continued in LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20230502112913
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: 05/19/2023
NARRATIVE
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Investigations revealed:

Regarding allegation: Staff did not notify resident's authorized representative of incident.

It was alleged that the facility staff did not call and tell R1’s authorized representative the R1 had been injured on 4/29/2023. Based on the Department’s records review, R1 is diagnosed with a dementia and R1 has an authorized representative. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Based on the department's record review, the facility reported an incident on R1's unusual incident that occurred on 4/29/2023. The “Unusual Incident/injury Report (LIC 624) shows the agencies/individuals notified were the Licensing, Long Term Care Ombudsman, Law Enforcement and the Adult/Child Protective Services, however, the Resident’s authorized representative was not provided a copy of this incident report. Based on interview, W2 revealed R1’s representative was not given a written notice of R1’s injury on 4/29/2023. Interview with S2 revealed R1’s authorized representative initiated a call to the facility and notified S2 that R1 had been injured on 4/29/2023. Based on gathered information, there is sufficient evidence to corroborate the above allegation.

Regarding allegation: Staff did not properly care for resident's wound.

It was alleged that staff applied a white cream on R1’s skin tear without a prescription or instructions from a medical professional. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Based on interviews conducted, three staff (S3, S4, and S5) and two witnesses (W1-W2) stated R1 was given a treatment by facility staff (caregiver) when R1 sustained a skin tear on the forearm on 4/29/2023. The topical medications applied by the caregiver to R1’s injured arm is called Calmoseptine and A&D. Based on records review, R1 has no prescription of Calmoseptine and A&D from a physician. Based on gathered information, there is sufficient evidence to corroborate the above allegation.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegations, "Staff did not notify resident's authorized representative of incident” and "Staff did not properly care for resident's wound." are found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6), the following deficiencies had been observed and citations issued (ref. LIC 9099D).

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Area Manager, Irene Formentera.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20230502112913
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/20/2023
Section Cited
CCR
87465(c)(1)
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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.

This was requirement was not met as evidenced by:
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Administrator shall review Section 87465 of Title 22 and shall self-certify understanding and compliance to this regulation. Administrator shall conduct an in-service training to staff involved in dispensing medications. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov. by the POC due date (5/20/2023).
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Based on interviews conducted, three staff (S3, S4, and S5) and two witnesses (W1-W2) stated R1 was given a treatment when R1’s sustained a skin tear on the forearm on 4/29/2023. The topical medications applied to R1’s injured arm are called Calmoseptine and A&D. Based on record review, R1 has no prescription of Calmoseptine and A&D from a physician. This poses an immediate health, safety and/or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20230502112913
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
06/02/2023
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement was not met as evidenced by:
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Administrator shall review Section 87211 of Title 22 and shall self-certify understanding and compliance to this regulation. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov. by the POC due date.
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Based on records review and interviews, the Resident’s authorized representative was not notified in writing of R1’s injury. A copy of the “Unusual Incident/injury Report” (LIC 624) was not provided to R1’s authorized representative. This poses a potential health, safety and/or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7