486830724-5-29-2024-21-AS-SMUU-D5QVDK-20240529162052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486830724
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:20:56 PM

Document Has Been Signed on 05/29/2024 04:20 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 LIFE CARE HOME		FACILITY NUMBER:	486830724
ADMINISTRATOR:	VERGELLIO SILVERIO		FACILITY TYPE:	740
ADDRESS:	1736 NEWARK LANE		TELEPHONE:	(707) 386-3888
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 4	DATE:	05/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	VERGELLIO SILVERIO, Administrator		TIME COMPLETED:	04:31 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 1 :26PM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by Marivic Dela Cruz,caregiver. Administrator, VERGELLIO SILVERIO arrived shortly after. The facility is a single story home licensed for six (6) non-ambulatory residents and a hospice waiver capacity of three (3). The facility currently provides care for 4 residents. In addition, there are some residents with a diagnosis of dementia. At approximately 1:46 PM, LPA toured the building and grounds which was found to be clean and in good repair. Administrator advised he has plans to paint some walls and areas. LPA observed all walkways and exits to be unobstructed. LPA observed external gate in need of repair, gate was dragging at the bottom and hinges are loose. Administrator agreed to repair gate. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room and kitchen. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 113.0 and 113.9 degrees F at three of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Five out of five Smoke detectors were present, inspected and found in working order. Carbon Monoxide detector was present, inspected and found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways. Continued on LIC809-Ca

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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

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 LIFE CARE HOME	FACILITY NUMBER: 486830724
	VISIT DATE: 05/29/2024

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
26
27
28
29
30
31
32

Continued from LIC809

Facility provides art therapist, nutritionist, and activity director paid by facility to ensure clients needs are met. Facility offers two areas for activities in the living room and a designated activity room in the garage.

Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Resident was observed interacting with staff in bedroom and living room. Two of four residents were found in their room. Two of four residents were at day program. LPA observed staff checking and caring for residents often.

At approximately 2:40PM, LPA reviewed Four of four resident records which were all found to be well organized, thorough and contained the required documentation. At approximately 3:10 PM , LPA reviewed four out of eight staff records which were all found to be well organized, thorough and contained the required documentation. Medication records are thorough and contained physician's orders for each resident. P&I is not commingled.

Administrator VERGELLIO SILVERIO Administrator Certification 6052484749 is current and expires on 07/20/2024.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident's
Liability Insurance
Surety Bond

No citations issued during today’s visit.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2