486804006-10-13-2023-21-AS-DTOA-CWKV8D-20231013161234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804006
Report Date: 10/13/2023
Date Signed: 10/13/2023 04:12:42 PM

Document Has Been Signed on 10/13/2023 04:12 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BRIGHT FUTURE CARE HOME		FACILITY NUMBER:	486804006
ADMINISTRATOR:	REYES, JOHN FRANCOIS DELOS		FACILITY TYPE:	740
ADDRESS:	830 DAFFODIL DR.		TELEPHONE:	(707) 386-3888
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	4	CENSUS: 3	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	John Francois Delos Reyes, Administrator		TIME COMPLETED:	04:25 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	On, 10/13/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrator, John Francoius Delos Reyes. The facility is licensed for all non-ambulatory rooms and a hospice waiver for two. The facility currently provides care for three residents, none of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were properly equipped with auditory alarms for residents with dementia, tested and found to be in working order. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/10/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food properly stored and labeled. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured in the kitchen, laundry room and garage area. Residents were observed engaging in discussion with staff in common areas and watching television in their bedrooms. Residents appear to have a positive relationship with staff based on LPA observations. Staff were observed continuously assisting and supervising residents and conducting room checks during LPA's inspection. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BRIGHT FUTURE CARE HOME	FACILITY NUMBER: 486804006
	VISIT DATE: 10/13/2023

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There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications are stored in a designated medication cabinet located in the common area and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. LPA found one prescription for client R2 not properly administered the previous evening of 10/12/2023. Licensee, Administrator and LPA discussed corrections. Technical Violation Issued.

A sample file review for staff was conducted and LPA found all staff to have sufficient 1st Aid & CPR certification and annual training on file. LPA also conducted a file review for all residents and found a majority of resident records updated. LPA found resident (R1) physician's report in need of updating. Technical Violation issued. Facility to submitted update facility sketch indicating all bedrooms are non-ambulatory based on current fire clearance.

LPA requested the following documents be sent to CCL by COB 11/13/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property

No deficiencies cited during today's visit

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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