486803788-8-17-2023-21-AS-CFOR-CUT3ZC-20230817184120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803788
Report Date: 08/17/2023
Date Signed: 08/17/2023 06:41:25 PM

Document Has Been Signed on 08/17/2023 06:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BRIGHT MINDS RESIDENTIAL CARE		FACILITY NUMBER:	486803788
ADMINISTRATOR:	DEAN, GRISSEL		FACILITY TYPE:	740
ADDRESS:	2598 BOXWOOD LN		TELEPHONE:	(707) 386-3888
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	08/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Annioraine Ebora, Caregiver		TIME COMPLETED:	07:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 8/17/2023 at approximately 2:50pm, and met with Annioraine Ebora, Caregiver. Administrator Grissel Dean Certificate #6063576740 and Administrator Arnel G Silvario Certificate, #6022666740 arrived at approximately 3:00pm. LPA observed two caregivers working at the time of arrival. There are currently six (6) residents in care. Facility has a required infection control plan. Facility has an emergency disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on 08/09/2023. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. All exits were free and clear of obstruction. Fire extinguisher, was last serviced on 06/19/2023 and tagged as required. LPA observed nine (9) smoke alarms and one (1) carbon monoxide detector, working properly during the inspection. Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 110.3 F, which is within regulation. Medications were stored and locked making them inaccessible to residents. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable for residents in care. Continue on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BRIGHT MINDS RESIDENTIAL CARE	FACILITY NUMBER: 486803788
	VISIT DATE: 08/17/2023

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Continue from LIC809

There are currently six (6) residents in care. LPA reviewed six(6) of six(6) resident files; All resident files were found to be complete.

LPA reviewed six (6) of six (6) staff files. LPA reviewed staff training. All six (6) staff have criminal record clearance, and are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 8/24/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Infection Control Plan-if any changes, as discussed
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited during today's inspection. Exit interview conducted with Administrator.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC809 (FAS) - (06/04)

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