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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607217
Report Date: 12/10/2024
Date Signed: 12/10/2024 11:29:55 AM

Document Has Been Signed on 12/10/2024 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRIGHTWATER GUEST HOME 3FACILITY NUMBER:
197607217
ADMINISTRATOR/
DIRECTOR:		IRENE FORMENTERAFACILITY TYPE:
740
ADDRESS:1620 IRIS AVENUETELEPHONE:
(310) 533-8060
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
12/10/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator - IRENE FORMENTERATIME VISIT/
INSPECTION COMPLETED:
11:40 PM
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On 12/10/2024 around 9:50 AM, the Department of Social Services (DSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced case management visit and met with Caregiver, Sherlyn Anoche. The purpose of the visit was explained to the Administrator, Irene Formentera.

A total of 5 residents are currently residing in this facility.

The department conducted a tour of the facility and gathered facility records.

No deficiencies were cited.

An exit interview was conducted, and a copy of this report was left with the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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