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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602093
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:26:17 PM

Document Has Been Signed on 11/03/2023 02:26 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRIGHTWATER MANORFACILITY NUMBER:
198602093
ADMINISTRATOR:PALMER, MATTHEWFACILITY TYPE:
740
ADDRESS:2305 230TH PLACETELEPHONE:
(310) 530-2443
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Sbina Dioneda, House ManagerTIME COMPLETED:
02:30 PM
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On 11/03/2023 at 8:36 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Sabrina Dioneda, House Manager. Four (4) residents and three (3) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents, two (2) may be bedridden. The facility also has an approved hospice waiver for six (6) residents. The Annual Licensing Fees are current.

The home consists of 1 floor level with: 1 staff room, 4 resident rooms, 2 bathrooms, kitchen, dining room, living room, and a garage.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured at 113 degrees (shower) and at 118.2 degrees (wash basin). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and garage and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Fire Department completed its fire inspection on 02/10/2023 and smoke detectors are interconnected. The facility has two carbon monoxide detectors near the three bedrooms. Last fire drill occurred on 10/09/23 1:30 PM.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRIGHTWATER MANOR
FACILITY NUMBER: 198602093
VISIT DATE: 11/03/2023
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5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates, health screenings, medical training and required criminal record clearances. 2 staff members were interviewed.

4 resident records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) or Hospice Care Plans. 2 residents medication was reviewed and 2 residents were interviewed.

An exit interview was conducted, and technical assistance provided. A copy of this report was discussed with Sabina Dioneda.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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