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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803971
Report Date: 06/04/2021
Date Signed: 06/04/2021 03:28:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BRIGHT LIFE CARE HOME IIFACILITY NUMBER:
486803971
ADMINISTRATOR:SILVERO, PRINCESS DIANAFACILITY TYPE:
740
ADDRESS:1043 SPARROW LANETELEPHONE:
(707) 386-3888
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 0DATE:
06/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Arnel Silverio, Applicant and Princess Diana SilverioTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Karina Canela and Jill Nakagawa conducted a pre-licensing inspection on 06/04/2021. LPAs met with Applicant Arnel Silverio and Princess Diana Silverio, who will be the Administrator when the facility is approved for licensure. The facility has a dementia care plan and has submitted a hospice waiver request. The facility has a fire clearance approval from the Fairfield Fire Department for 5 non-ambulatory and 1 ambulatory residents for a total capacity 6. Facility will operate with a live-in staff and Licensee will ensure sufficient staffing at all times.
During today’s visit LPAs observed the following items:
· COVID-19 postings and screening station at entrance
· Lockable separate cabinets for medications, toxin, and knives.
· All exits were unobstructed
· 12 hardwired combination smoke and carbon monoxide detectors, which were tested and observed to be operational
· First Aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip mats in 2 of 2 bathrooms.
· Fire Extinguisher charged and serviced 07/24/2020
· Required furnishings in all 6 resident bedrooms
· A shed in the backyard used for storage
· Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy).

Pre-licensing is complete and this facility has no deficiencies.

The Component III Orientation was completed during today's visit. LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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