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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803618
Report Date: 04/21/2025
Date Signed: 04/21/2025 02:22:17 PM

Document Has Been Signed on 04/21/2025 02:22 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A BRIGHT FUTURE ACADEMYFACILITY NUMBER:
286803618
ADMINISTRATOR/
DIRECTOR:		KONAN, MAXIMEFACILITY TYPE:
775
ADDRESS:3419 BROADWAY STREET H 4-5-6TELEPHONE:
(510) 692-1804
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 45CENSUS: 17DATE:
04/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH: Alexis Hernandez, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Alexis Hernandez, Program Director. Facility is an Adult Day Program (ADP) with seventeen (17) clients in care. Facility is serviced by vendor North Bay Regional Center (NBRC). Upon Review of LIC500 - Personnel Report, LPA observed one staff (S1) working who did not have an eligible background clearance and one staff (S2) not currently working who was not associated to the facility (civil penalty for repeat deficiency within a 12 month period issued).

At approximately 11:00 AM, LPA initiated a tour of the facility with Program Director and observed the following: Facility is a one (1) story building, was a comfortable temperature, and passageways were free from obstructions. Facility's fire extinguishers were observed charged and last serviced 3/25. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperatures in client bathrooms read at between 105.2 degrees F and 109.7 degrees F which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply paper, sanitary, and personal hygiene products available for clients. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has an internet access devise and internet available to clients in care, and the phone was tested and operational during today's inspection. Facility has plenty of board games, arts and crafts materials, and other activities for clients. Facility also takes clients out on day trips to museums, parks, and other parts of the community. LPA observed twelve (12) of the clients leaving and returning on an outing during this visit. The five (5) clients who did not wish to attend were left with sufficient supervision and activities to entertain them. Facility does not handle client medication nor cash resources.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A BRIGHT FUTURE ACADEMY
FACILITY NUMBER: 286803618
VISIT DATE: 04/21/2025
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Continued from LIC809...

Facility conducts monthly disaster drills, and the most recent drill was conducted 3/25. LPA observed facility's infection control plan and emergency disaster plan which was last updated 10/24. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. At approximately 11:30 AM LPA conducted a review of five (5) resident records, all required documentation present. At approximately 12:30 PM LPA conducted review of five (5) staff records, all required documentation present.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC308 - Designation of Responsibility
Rental Agreement

LPA is issuing a citation today for Civil Penalties for a repeat violation in less then 12 months.

Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 1522(c)(1) Personnel Records - Training in less than 12 months. Deficiency last cited on 5/17/2024.

*******Total Civil Penalties being given today $250


Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided.

Exit interview conducted with Program Director, whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2025 02:22 PM - It Cannot Be Edited


Created By: Elias Magdaleno On 04/21/2025 at 01:22 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A BRIGHT FUTURE ACADEMY
FACILITY NUMBER: 286803618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Observation and records reviewed, the licensee did not comply with the section cited above. One staff was working in the facility without a background clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Licensee shall ensure all staff receive a background clearance or exemption and be associated to facility prior to working with clients. Licensee to submit self certification that all staff will receive a clearance or exemption prior to returning to the facility. Self certification shall be submitted to CCL by POC date of 04/22/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Elias Magdaleno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
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