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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602944
Report Date: 09/25/2022
Date Signed: 09/25/2022 01:38:51 PM


Document Has Been Signed on 09/25/2022 01:38 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:BRIGHT SUNLIFE GUEST HOMEFACILITY NUMBER:
198602944
ADMINISTRATOR:MORALES, MARIOFACILITY TYPE:
740
ADDRESS:22633 VAN DEENE AVETELEPHONE:
(424) 558-8761
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:6CENSUS: 6DATE:
09/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angel CulalaTIME COMPLETED:
01:59 PM
NARRATIVE
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On 09/25/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with house manager Angel Culala and explained the purpose of today’s visit. Culala contacted administrator Heidi Skiles by telephone who was not able to join. The facility is licensed to operate for (6) residents of which (4) non-ambulatory and maybe (2) bedridden elderly residents ages 60 and above. The facility is approved for (4) hospice residents. Currently, the home has (2) hospice residents in care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside area.
LPA toured the physical plant. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be operational. The water temperature measured 109.0 F. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food maintained properly. There are (2) fire extinguishers that are fully charged at the facility and smoke detectors that are functioning. A working landline telephone remains available.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2022
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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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: BRIGHT SUNLIFE GUEST HOME
FACILITY NUMBER: 198602944
VISIT DATE: 09/25/2022
NARRATIVE
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DEFICIENCIES:

The LPA identified that 3 out of 5 stove burners were not operable and had to be lit with matches at 9:45 am. LPA identified the overhead stove hood range with unsanitary and unsafe. LPA identified at 9:47 am kitchen cabinets with sharp knives and hazardous cleaning solutions unlocked cabinets. LPA identified at 9:50 am the kitchen trash and bathroom trash bins unsanitary without lids. At 10:00 am, LPA observed in bathroom #2 a tub unsanitary and with uncleaned floor surfaces. The LPA observed staff #2 (S2) without a facial mask while assisting the resident. LPA observed medication administration records and daily temperature logs not maintained on daily basis. The (MARs) showed last 09/21/22 and temperature log 05/2022.



Deficiencies are issued and an exit interview is conducted with Angel Culala. A copy of this report is provided along with the appeal rights.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/25/2022 01:38 PM - It Cannot Be Edited

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: BRIGHT SUNLIFE GUEST HOME
FACILITY NUMBER: 198602944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified unlocked kitchen cabinets with sharp objects, knives and hazardous chemicals in unlocked storage cabinets. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations 87309. The licensee will ensure that hazardousr items that pose danger to residents in care are in locked storage at all times. Proof of correction must be sent to CCLD via fax 323-981-1781 by (POC) 09/26/22. *This was corrected during visit.*
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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2022 01:38 PM - It Cannot Be Edited

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: BRIGHT SUNLIFE GUEST HOME
FACILITY NUMBER: 198602944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified bathroom #2 tub with soap, dirt and grime between tile and tub. The tub is unsanitary and requires deep cleaning. The violaton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations 87303. The licensee will ensure that all bathroom surfaces are sanitary and safe at all times. LIcensee will ensure to do some deep cleaning. Proof of correcction must be sent to CCLD via fax 323-981-1781 by (POC) 10/10/22.
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation, the licensee did not comply with the section cited above. LPA observed kitchen and bathroom trash bins unsanitary without lids. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations 87303. The licensee will ensure to keep the facility in healthful and safe environment. Licensee to purchase trash bins with cover lids .Proof of correction must be sent to CCLD via fax 323-981-1781 by (POC) 10/10/22.

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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/25/2022 01:38 PM - It Cannot Be Edited

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: BRIGHT SUNLIFE GUEST HOME
FACILITY NUMBER: 198602944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA observed stove overhead hood unsanitary and unsafe with grease and grime. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations 87555. The licensee will ensure to maintain a safe and healthful enviroment. Kitchen surfaces must be kept clean at all time including overhead stove hood. Proof of correcction must be sent to CCLD via fax 323-981-1781 by (POC) 10/10/22.
Type B
Section Cited
CCR
87555(29)
(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified 3 out of 5 stove burners not working properly and had to use a match to start the burners manually. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations 87555. The licensee will ensure to repair the (3) burners that are in not working condition. Proof of correction must be sent to CCLD via fax 323-981-1781 by (POC) 10/10/22.

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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/25/2022 01:38 PM - It Cannot Be Edited

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: BRIGHT SUNLIFE GUEST HOME
FACILITY NUMBER: 198602944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(2)
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) and (record review), the licensee did not comply with the section cited above. LPA observed staff #2 with no mask. During record review, LPA observed daily temperature checks for residents/staff not maintained. LPA observed (MARs) not maintained daily for accuracy. LPA observed staff did not properly screen a visitor during entry. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations 87468.1. The licensee will ensure that all staff wears a mask when assisting residents in care. Daily maintained records of temperature logs for staff & residents. Daily records of medication administration records for residents in care must be maintained daily for accuracy. Proof of correction must be sent to CCLD via fax 323-981-1781 by (POC) 10/10/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6