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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006333
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:10:20 PM

Document Has Been Signed on 05/06/2025 05:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SHINING BRIGHT CARE HOMEFACILITY NUMBER:
306006333
ADMINISTRATOR/
DIRECTOR:		BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:697 PLUMER STREETTELEPHONE:
(714) 749-9353
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 15CENSUS: 10DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Aurora TecsonTIME VISIT/
INSPECTION COMPLETED:
05:24 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 15 non-ambulatory residents. Facility has an approved hospice waiver for 15 residents and the home currently has 10 residents, with 2 residents on hospice. Administrator (AD) Aurora Tecson arrived shortly to help conduct facility visit. AD provided updated liability insurance that expires on 07/06/2025.

LPA along with staff toured the facility at 12:10 PM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 8 resident bedrooms, living room, dining room, and kitchen as well as 2 bathrooms on the first floor. The second floor consists of an office and two staff rooms. No residents in care are in the second floor. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed all resident beds had bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 119.3 degrees F and 119.8 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough.
Continued on LIC809-C dated 05/06/2025.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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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Document Has Been Signed on 05/06/2025 05:10 PM - It Cannot Be Edited


Created By: Fred Arias On 05/06/2025 at 04:02 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHINING BRIGHT CARE HOME
FACILITY NUMBER: 306006333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, client 7 did not get the doses administered per physician's orders for seven medications in the month of May which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Facility to do in service training and submit to LPA
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/06/2025 05:10 PM - It Cannot Be Edited


Created By: Fred Arias On 05/06/2025 at 04:02 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHINING BRIGHT CARE HOME
FACILITY NUMBER: 306006333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, bedroom 7 exit door has a detached door hinge. Four cameras with built in audio are placed in the common areas. All which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Facility to repair detached door hinge. Facility to remove or replace Link cameras with another model without audio hardware. LPA to return after POC due date to verify.
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, exit gate closest to garage is locked and inaccessible which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Facility to keep gates unlocked from now on. In service training to be completed and sent to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SHINING BRIGHT CARE HOME
FACILITY NUMBER: 306006333
VISIT DATE: 05/06/2025
NARRATIVE
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Facility conducts quarterly emergency drills with the last drill conducted on 03/25/2025. Outside grounds were toured. Walkways around the home were clear of hazards. There is shaded outdoor seating for residents. At 12:40pm one out of two exit gates leading to the street was observed to be locked. LPA observed the emergency food and water supply. At 12:50pm, LPA observed four Link cameras with audio capabilities in the common areas of the facility. LPA reviewed six resident files and four staff files. All resident files contained required documentation including admission agreements, physician reports and resident appraisals. Nine out of ten resident files did not contain physician's orders for bed rails. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. At 3:21pm, LPA observed medication for client 7 was not given as prescribed per physician's orders. LPA was unable to test the smoke alarms as they are serviced by a third party company. Facility did not have records of the last service date.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/06/2025 05:10 PM - It Cannot Be Edited


Created By: Fred Arias On 05/06/2025 at 04:35 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHINING BRIGHT CARE HOME
FACILITY NUMBER: 306006333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
A written order from the physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, 9 out of 10 residents with bed rails did not have bed rail orders which poses a potential health and safety risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Facility to email bed rail orders for all residents to LPA.
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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