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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602288
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:17:06 PM

Document Has Been Signed on 02/23/2022 02:17 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BRIGHTSIDE RESIDENTIAL INCFACILITY NUMBER:
198602288
ADMINISTRATOR:DUKES, KIPCHOGEFACILITY TYPE:
735
ADDRESS:517 RICHBROOK DRIVETELEPHONE:
(909) 622-5603
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:S-1TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced annual inspection. LPA was allowed entry by S-1.

There are (3) clients residing at this home. This single story home consists of (3) bedrooms, 2 bathrooms, living room, kitchen, dinning area and attached garage. Annual Licensing fees are current.

The following were observed/inspected:
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • PPE and hygiene supplies observed. These items are stored inside the office.
  • Restrooms have hand soap and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per Administrator, all (3) clients are fully vaccinated and have their booster.
  • Per Administrator, all staff are fully vaccinated.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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