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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880972
Report Date: 03/23/2022
Date Signed: 03/23/2022 03:28:19 PM

Document Has Been Signed on 03/23/2022 03:28 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A BRIGHTER HORIZON ADULT RESIDENTIAL INCFACILITY NUMBER:
331880972
ADMINISTRATOR:GARCIA, PORTIAFACILITY TYPE:
735
ADDRESS:1731 STEINBECK AVETELEPHONE:
(951) 287-9525
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 4CENSUS: 2DATE:
03/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Licensee, Portia GarciaTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA), Janira Arreola and David Cuevas conducted an unannounced Case Management visit to facility regarding a death report received at regional office on 03/22/2022. LPA 's met with Licensee, Portia Garcia who was informed of the propose of visit and granted entry.

During case management visit LPA's interviewed staff #1(S1) and reviewed residents #1 (R1)’s file.

Per interviews and available records resident passed away on 03/17/2022 at the Hospital. Hospitalization was due to a 911 called made by staff on 3/7/22 approximately 7:49PM after staff identified a change in condition, for R1. Per interview with S1, R1 lost pulse while staff waited for 911 to arrive, after staff communicated lost pulse dispatch instructed staff to initiate CPR compression until emergency personnel arrived. Upon emergency personnel arriving at facility they took over R1's CPR compressions. R1 was admitted to hospital on 3/7/22 and remained there until day of death on 3/17/22. Per S1 on 3/16/22 R1’s family met with Doctors who communicated to family that R1 was brain dead at that time R1’s family made the decision to donate R1’s organs and on 3/17/22 R1 was taken of respirators. During todays visit LPA's requested the following documents:

· Admission Agreement

· Needs and Service Plan

· Psychiatric Evaluation and Medical Notes/Orders

· Unusual Incident Reports

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A BRIGHTER HORIZON ADULT RESIDENTIAL INC
FACILITY NUMBER: 331880972
VISIT DATE: 03/23/2022
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· Resident Daily Notes

· ID/ Emergency Information

· Physicians Report

· Medication Administration Records (MAR)

· Personal Property Record

· Weight Record

· Laboratory Paperwork.

No coroners report available yet, however, per S1 report will be requested and provided to CCL when available.

An exit interview was conducted, were this report was reviewed and provided to Licensee, Portia Garcia.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
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