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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880983
Report Date: 03/29/2023
Date Signed: 03/29/2023 01:44:50 PM

Document Has Been Signed on 03/29/2023 01:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRIGHT MORNING STAR FAMILY HOME 3FACILITY NUMBER:
331880983
ADMINISTRATOR:DENILA, LELANIE F.FACILITY TYPE:
735
ADDRESS:1707 GOLDEN WAYTELEPHONE:
(909) 635-4662
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 1DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Annaliza Lazo House ManagerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived to the Bright Morning Star Family Home #3 Adult Resident Facility unannounced to conduct an Annual Inspection. LPA knocked on the door and was greeted and granted entry by the Facility Manager Annaliza Lazo. LPA introduced self and stated the purpose of the visit. LPA was asked to have temperature taken and to sign in. Administrator was contacted during the visit to notify them of LPA visit. Facility Manager. informed LPA the current census is 1, but the resident was attending a day program at the time of visit. LPA's visit included a walk through of the facility grounds, file reviews of staff and resident charts and staff interview.

While signing in, LPA observed a COVID station near front entrance of the facility. COVID station included information regarding infection control and offering PPE and hand sanitizer to those who visit.

Personnel Records/Training/and Staffing- LPA reviewed employee records. LPA observed employee record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification.

Client Room was found to be clean, spacious and orderly. Included all required furniture and in good conditions.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of the resident record available. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, emergency contact information, progress notes, safeguard for personal property/valuables, record of behaviors and personal rights notification.

Please see LIC809C**

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRIGHT MORNING STAR FAMILY HOME 3
FACILITY NUMBER: 331880983
VISIT DATE: 03/29/2023
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Food Service- LPA observed the pantry, refrigerators and emergency supply of food in the facility. All food was labeled with the date of purchase and expiration dates. All food, perishable and non perishable was observed to be in good standing and or good quality. Food Menu was observed posted in the kitchen. Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand. Sharp objects and cleaning solutions observed in a secure cabinet under the kitchen sink.

Emergency food supplies are kept in the facility's garage. Food packed also in good standing and of good quality. Fire/Smoke/Carbon Monoxide Alarms tested during visit and found operational. Fire Extinguishers were observed fully charged with the last inspection date of January 2023. LPA observed the facility's van used for transport in the garage. Vehicle appeared to be in good condition and operational.

Activity Materials were observed through out the facility (board games, coloring sheets and puzzles) Activity Calendar observed posted in hallway.

An exit interview was conducted, and a copy of this report LIC 809 and LIC809C was discussed and provided to the Facility Manager, Annaliza Lazo

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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