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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610305
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:35:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20221020145038
FACILITY NAME:BRIGHTSTAR SENIOR CARE,INCFACILITY NUMBER:
197610305
ADMINISTRATOR:ALLAHDADI, AYEDEHFACILITY TYPE:
740
ADDRESS:10455 GAYNOR AVETELEPHONE:
(818) 517-0544
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 4DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ayedeh Allahdadi/ AdministratorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Resident did not receive a copy of their Admissions Agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patrick Shanahan, arrived at the facility in response to the above mentioned allegation. The LPA was greeted by facility staff and the administrator was called and arrived a short while later.
Allegation 1. Resident did not receive a copy of their Admissions Agreement.
The LPA was able to interview staff and residents regarding this allegation. The facility staff and the facility administrator both confirmed that an admission agreement had been completed. Both the staff and the administrator also confirmed that one resident had requested a copy of the report, but due to a slow printer a copy was not provided to the resident. One out of the 4 residents interviewed also confirmed that an admission agreement was requested but was not provided.

Based on interviews conducted with residents and admission from staff and the administrator, this allegation is deemed SUBSTANTIATED.
Exit interview conducted, deficiency cited and report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20221020145038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BRIGHTSTAR SENIOR CARE,INC
FACILITY NUMBER: 197610305
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
87507(e)
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The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.
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Administrator provided a signed copy of the admissions agreement during the visit.

Cleared during visit
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This requirement was not met as evidenced by, the administrator did not provide a copy of the admissions agreement to the resident when requested, which poses a potential risk to the residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2