198602093-3-24-2022-11-AS-LMOA-CCTREG-20220324125731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602093
Report Date: 03/15/2022
Date Signed: 03/24/2022 12:58:06 PM

Document Has Been Signed on 03/24/2022 12:58 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	BRIGHTWATER MANOR		FACILITY NUMBER:	198602093
ADMINISTRATOR:	PALMER, MATTHEW		FACILITY TYPE:	740
ADDRESS:	2305 230TH PLACE		TELEPHONE:	(310) 530-2443
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 5	DATE:	03/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Matthew Palmer		TIME COMPLETED:	11:30 AM

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On 3/15/2022, Licensing Program Analysts (LPAs) Lourdes Montoya and Antonia Alvizar conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool.

Upon arriving at the facility, LPAs met with Facility House Manager, Sabina Dioneda, who granted access and allowed LPA to enter the facility to conduct an annual inspection. Administrator Matthew Palmer joined the visit shortly after. The facility is licensed for two (2) ambulatory and four (4) non-ambulatory residents of which two (2) may be bedridden and an approved hospice waiver for three (3) residents. Currently, there are four (4) Hospice residents present during today’s visit. The facility does not handle residents’ cash resources. Facility Annual Fees are current during today’s visit. Administrator's certificate expires 6/1/2022.

During the visit, LPAs toured the facility with HM Dioneda and Administrator Palmer. This facility consists of four (4) resident bedrooms, two (2) full bathrooms, kitchen, living room/TV room, dining area, office area, staff bedroom adjacent to the kitchen, shaded patio (located in the backyard), and a garage. Operable smoke detectors in bedrooms and hallways were observed. Two operable carbon monoxide detectors located in the living room/TV room and resident bedroom #1 are operable. Two fire extinguishers last serviced on 8/19/2021 are located in the kitchen and hallway. The facility has interconnected fire sprinklers. The last facility fire drill was on 3/9/2022. LPAs observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

Report Continued in LIC 809-C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: BRIGHTWATER MANOR	FACILITY NUMBER: 198602093
	VISIT DATE: 03/15/2022

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There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. Potentially dangerous items are kept inaccessible to residents with dementia. Centrally stored medications are locked in a cabinet located in the kitchen. The first aid kit has all required supplies.
Toxic chemicals are locked in a cabinet in the kitchen. The facility has a written emergency disaster plan posted in the living room/TV room. The facility is maintained at a comfortable temperature. LPAs observed hot water temperature in both common bathrooms measure 116.3 degrees Fahrenheit and 112.9 degrees Fahrenheit. There are working lights or lamps in each room at the time of visit. There are grab bars for each toilet and shower used by residents. Showers have non-skid mats.

During the visit, LPAs observed the following to be in compliance: facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

The following technical violation was given to the licensee:
Licensee accepted a Hospice Resident (R#1) prior to obtaining a hospice waiver. License submitted a hospice waiver request on 3/7/2022 which CCLD is still processing.

Exit interview conducted. A copy of this report was provided to the Administrator Matthew Palmer.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC809 (FAS) - (06/04)

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