306006333-6-27-2023-22-AS-DLMN-CT7P78-20230627110331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006333
Report Date: 06/27/2023
Date Signed: 06/27/2023 11:03:39 AM

Document Has Been Signed on 06/27/2023 11:03 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SHINING BRIGHT CARE HOME		FACILITY NUMBER:	306006333
ADMINISTRATOR:	BULLER, KATHRINA		FACILITY TYPE:	740
ADDRESS:	697 PLUMER STREET		TELEPHONE:	(714) 749-9353
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY: 15		CENSUS: 0	DATE:	06/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kathrina Buller		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by designated Administrator (AD) Kathrina Buller. An application to operate a Residential Care Facility for Elderly (RCFE) for (15) capacity, (0) ambulatory, (15) non-ambulatory, and (0) bedridden clients was received by CCL on 6/2/2023. Structure: The facility is a two-story home with eight resident bedrooms, three bathrooms, living room, kitchen, dining room two staff bedrooms, staff bathroom and an attached two car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining room area. There is a back yard with two exit gates on each side of the house. There are five shaded seating areas in the backyard. LPAs did not observe any obstacles or hazards in the backyard. Client Bedrooms All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened. Signal system There is signal system that each of the residents will have access to via handheld device. Each device sends a signal to the signal system’s interface in the med room. This signal will let the staff know which resident needs assistance. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked beneath the kitchen sink.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHINING BRIGHT CARE HOME	FACILITY NUMBER: 306006333
	VISIT DATE: 06/27/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the kitchen.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has activity materials that will be kept in the dining room area. Puzzles, Bingo, card games and other games will also be kept for resident use.

Fire clearance:
Was approved by a fire inspector of City of Costa Mesa Fire Prevention on 05/31/2023.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

Two bedrooms will be occupied by staff.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 106.3 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHINING BRIGHT CARE HOME	FACILITY NUMBER: 306006333
	VISIT DATE: 06/27/2023

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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