486803873-9-13-2024-21-AS-JFLO-D944VD-20240913192610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803873
Report Date: 09/13/2024
Date Signed: 09/13/2024 07:26:19 PM

Document Has Been Signed on 09/13/2024 07:26 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 PATH CARE HOME		FACILITY NUMBER:	486803873
ADMINISTRATOR:	DEAN, GRISSEL		FACILITY TYPE:	740
ADDRESS:	2170 HAUSAM LANE		TELEPHONE:	(707) 386-3888
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kristine Lorenzo, House Manager/Designated Responsible Party		TIME COMPLETED:	07:35 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	At approximately 9:40 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted Staff 1 (S1) and Staff 2 (S2). Kristine Lorenzo, House Manager/Designated Responsible Party (RP) was contacted and arrived at approximately 10:05 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6 ) residents in care. LPA was informed that Resident 1 (R1) and Resident (2) were away at Day Program and the remaining four (4) residents were present during today's visit. Facility has a hospice waiver for two (2), a bedridden waiver for one (1), is approved for all non-ambulatory residents, and is vendorized with North Bay Regional Center (NBRC). At approximately 10:30 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Licensee stopped by at approximately 11:15 AM and ordered the facility an evacuation chair. Water temperatures in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA advised House Manager and Licensee to ensure all such items are secured and inaccessible to residents when not being used. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPA observed an activity schedule and was informed that each NBRC client has their own internet access device and the facility has an additional device available for resident use. Facility has internet available to clients in care and the phone was tested an operational. Facility's fire extinguisher was observed charged and was last serviced July 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 PATH CARE HOME	FACILITY NUMBER: 486803873
	VISIT DATE: 09/13/2024

NARRATIVE

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Continued from LIC809...

Facility conducts regular monthly disaster drills, and the most recent drill was conducted September 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated January 2024. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. RP states the facility has a backup solar battery if needed.

At approximately 12:00 PM, LPA reviewed five (5) staff files and six (6) resident files. Five (5) of five (5) staff files reviewed have the required paperwork and proof of current First Aid and CPR training. However, six (6) of six (6) staff were short one hour of medication training. (See LIC809D). Five (5) of five (5) resident files reviewed have all the required paperwork. RP coordinates medical and dental visits for the clients and take them to their appointments.

At approximately 3:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. However, LPA observed 7/9 instances where staff did not follow the physician's order and instructions for the proper administration of a medication for Resident 3 (R3). (See LIC809D). LPA reviewed P&I monies and logs, which were organized, maintained, and stored according to regulation.

RP informed LPA that the Licensee has appointed them as the new facility Administrator. LPA discussed the process and the documents that need to be submitted to CCL to make the change official with Licensing.

Required Change of Administrator Documents:

LIC 308 (Designation of Facility Responsibility)
Active and Current Administrator Certificate
First Aid Certificate
LIC 500 (Personnel Report)

Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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 PATH CARE HOME	FACILITY NUMBER: 486803873
	VISIT DATE: 09/13/2024

NARRATIVE

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Continued from LIC809C...

LIC 501 (Personnel Record)
LIC 503 (Health Screening Report - personnel)
Proof of Negative TB test
LIC 9182 (Criminal Record Exemption Transfer Request)
LIC 508 (Criminal Record Statement)
Copy of Driver's License or Passport that is not expired
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)
Copy of New Liability Insurance Policy
Copy of New Facility Lease

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with RP and Appeal rights were given. Signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 07:26 PM - It Cannot Be Edited

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 PATH CARE HOME	FACILITY NUMBER: 486803873
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(b)

Other Provisions

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviewed, and record review, the licensee did not comply with the section cited above in 5 out of 5 staff training records reviewed which were missing one hour of their annual medication training each, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	RP to submit proof of completion of medication training for identified staff to CCLD by POC dues date 9/27/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 07:26 PM - It Cannot Be Edited

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 PATH CARE HOME	FACILITY NUMBER: 486803873
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)

80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 7 out of 9 instances of medication administration reviewed where medication was not given according to the physician's instructions which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	RP to submit self certification that all staff have been coached and have been signed up for medication administration training regarding giving medications per physician's instructions to CCLD by POC due date 9/16/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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