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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005306
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:52:21 AM


Document Has Been Signed on 09/13/2023 11:52 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SHINING BRIGHT SENIOR CARE HOMEFACILITY NUMBER:
306005306
ADMINISTRATOR:BULLER, KATHRINA P/GARRYFACILITY TYPE:
740
ADDRESS:9232 MARCHAND AVENUETELEPHONE:
(714) 749-9353
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 5DATE:
09/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jessica Villanueva, Garry BullerTIME COMPLETED:
10:00 AM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the Pre-licensing inspection conducted at KRISNELLE HOME CARE (306006336) on 09/13/23. LPA met with Applicant (AP) Jessica Villanueva and explained the reason for today’s inspection. Administrator (AD) Garry Buller appeared via telephone.

During the course of the inspection, LPA and AP observed the following: toxins accessible to residents, including residents with Dementia, in the non-lockable garage, including laundry detergent, mechanical oils and lubricants, and drain cleaner; Resident #1’s (R1) bed had a half bedrail with a corresponding doctor’s order, but the bed rail was in the middle of the bed; Resident #2’s (R2) bed had a oversized half bedrail without a corresponding doctor’s order; Resident #3’s (R3) bed had a half bedrail in the middle of the bed without a corresponding doctor’s order; and Resident #4’s (R4) bed had a half bedrail without a corresponding doctor’s order. During the inspection, AP secured the toxins, removed bed rails without doctors’ orders or that were placed incorrectly, and ensured all bedrails have corresponding doctors’ orders and extend from the head half the length of the bed.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/13/2023 11:52 AM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SHINING BRIGHT SENIOR CARE HOME
FACILITY NUMBER: 306005306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2023
Section Cited
CCR
87309(a)

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87309 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. This requirement was not met as evidenced by:
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During the inspection, the licensee secured these items and LPA confirmed. POC CLEARED.
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Based on observations, the licensee did not ensure laundry detergent, mechanical oils and lubricants, and drain cleaner were inaccessible to residents in the non-lockable garage, which poses a potential health and safety risk to persons in care.
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Type B
09/20/2023
Section Cited
CCR87608(a)(3)

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87608 Postural Supports. (a) ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement was not met as evidenced by:
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During the inspection, the licensee removed bed rails without doctors’ orders or that were placed incorrectly and ensured all bedrails have corresponding doctors’ orders and extend from the head half the length of the bed. POC CLEARED.
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Based on observations and documents, the licensee did not ensure 4 residents had doctors’ orders for their bedrails, which poses a potential safety and personal rights risk to persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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