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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202408
Report Date: 02/08/2024
Date Signed: 02/09/2024 01:07:53 PM

Document Has Been Signed on 02/09/2024 01:07 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BRIGHT HAVEN MANORFACILITY NUMBER:
435202408
ADMINISTRATOR:MARIESON FLOREZAFACILITY TYPE:
735
ADDRESS:2706 WILBUR AVENUETELEPHONE:
(408) 629-8804
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Marieson FlorezaTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted a annual inspection visit, and met with administrator (ADM) Marieson Floreza. entrance. 2 staff were observed in facility and all 5 residents went to day program.

LPA reviewed 3 resident files and 3 staff files.

LPA toured the facility inside and out with ADM. License, personal rights poster and Administrator Certificate were observed at the main entrance. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, were observed locked. Cleaning product cabinet under the sink in kitchen was observed unlocked. There are three shared rooms for residents, one office, and two staff live-in rooms in facility. 2 bathrooms were inspected. The window screen in one resident bedrooms was observed missing. 2 days perishable food supplies and 7 days food supplies were observed sufficient. Room temperature was observed at 72 degree F, and hot water temperature was observed at 118 degree F. The temperature of the refrigerator was at 40 degree F, and the temperature of the freezer was at 0 degree F.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 07/20/2023. First aid box, flash lights, and night lights were observed in the facility. The facility's last time emergency and fire drill was conducted 1/18/24. LPA inspected the backyard, there was no obstruction to block the walkway.

Deficiency noted for today's inspection. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/09/2024 01:07 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/08/2024 at 10:58 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BRIGHT HAVEN MANOR
FACILITY NUMBER: 435202408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the detergent in the kitchen was observed unlocked, which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Administrator stated to submit a plan of correction to CCL office by the POC due date, administrator already put the detergent in the cabinet in the kitchen and locked it.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the window screen in one of the resident bedrooms was observed missing, which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Administrator stated the facility to submit a plan of correction to CCL office by the POC due date to install a window screen for the resident bedroom.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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