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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602093
Report Date: 11/01/2024
Date Signed: 11/01/2024 04:30:51 PM

Document Has Been Signed on 11/01/2024 04:30 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 MANORFACILITY NUMBER:
198602093
ADMINISTRATOR/
DIRECTOR:
PALMER, MATTHEWFACILITY TYPE:
740
ADDRESS:2305 230TH PLACETELEPHONE:
(310) 530-2443
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 3DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:House Manager Sabina DionedaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 11/01/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with House Manager Sabina Dioneda. LPA spoke with Administrator Matthew Palmer over the phone. Facility is licensed to serve six (6) non-ambulatory residents of which two (2) may be bedridden. The facility also has an approved hospice waiver for six (6) residents.

The home consists of one staff room, four resident rooms, two bathrooms, kitchen, dining room, living room, and a garage. The facility is clean, sanitary, and in good repair. Protective devices are in place, including non-slip mats and grab bars in all showers.

Caregiver accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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Document Has Been Signed on 11/01/2024 04:30 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/01/2024 at 03:57 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 MANOR

FACILITY NUMBER: 198602093

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for Staff #2 - #4 which poses a potential health and safety risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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The Licensee will email the plan of correction to regina.cloyd@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


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 MANOR
FACILITY NUMBER: 198602093
VISIT DATE: 11/01/2024
NARRATIVE
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Common areas were clean, clear of hazards, and doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. Two fire extinguishers last serviced September 2023 was observed in the kitchen and dining area. Fire prevention inspection was conducted on 02/29/2024.

Five staff records were reviewed and five out of five staff records had current first aid certificates and required criminal record clearances or criminal record exemptions.

Three resident records were reviewed and three out of three resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medications was reviewed.

Deficiencies are being cited. Based on record review, staff #2 - #4 did not complete their annual training (see LIC809-D).

An exit interview was conducted, technical assistance provided, and a copy of this report with appeal rights was discussed and left with the House Manager Sabina Dioneda.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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