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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700123
Report Date: 11/05/2021
Date Signed: 11/09/2021 05:46:02 AM

Document Has Been Signed on 11/09/2021 05:46 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BRIGHT FUTURES IFACILITY NUMBER:
392700123
ADMINISTRATOR:GINA HERNANDEZFACILITY TYPE:
735
ADDRESS:2602 BREAKER WAYTELEPHONE:
(209) 227-5983
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 5CENSUS: 5DATE:
11/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gina Hernandez, Facility AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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A case management visit was conducted at the care home to review and discuss an incident involving a resident. Licensing Program Analyst met with Facility Administrator Gina Hernandez to discuss and incident and review client's record. the facility submitted an incident report documented that a resident has left the facility and his whereabouts were unknown. A Police Report and SIR was filed. LPAS reviewed the report and asked for the Physician Report (LIC 602) and it was determined that the facility had not yet received the report for this client that moved in on 6/28/21. In the client's record, it was determined that there was not a Physician's Report (LIC 602) as required. History of client documents he has a history of elopements. Two deficiencies are issued and the following 809D

Copy of report given to the facility along with the citation and appeal rights.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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Document Has Been Signed on 11/09/2021 05:46 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 11/05/2021 at 07:34 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BRIGHT FUTURES I
FACILITY NUMBER: 392700123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
85078(a)(1)

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Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply:

(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs
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Plan of correction: The facility will review the incident with staff and provide in-service training to all staff on supervision and care plans. The facility currently has 24 hours a day staff to supervise the resident and the facility will assess other factors in supervision and safety of the client and submit a corrective action plan by 12/17/21.
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This requirement was not met as evidenced by: An incident was submitted documenting the resident left the facility without the staff's knowledge. A police report was made and the resident was brought back to the home later that day. Client records show the client has a history of elopement
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This is an immediate Health and Safety risk to client in care
Type B
12/06/2021
Section Cited
CCR80070(b)(8)

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Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
(b) Each record must contain information including, but not limited to, the following:
(8) Medical assessment, including ambulatory status, as specified in Section 80069.
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Plan of correction: The facility will review all five client files and ensure that all required records and documents are in file. The facility will submit at a corrective action plan by the POC due date.
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This requirement was not met as evidenced by: There was no record of a Physician's Report (LIC 602) in the client's record. This poses a potential Health and Safety risk to client in care. Client moved into the home on 6/28/21
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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:Liza King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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