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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803971
Report Date: 06/20/2022
Date Signed: 06/21/2022 08:51:51 AM

Document Has Been Signed on 06/21/2022 08:51 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRIGHT LIFE CARE HOME IIFACILITY NUMBER:
486803971
ADMINISTRATOR:SILVERO, PRINCESS DIANAFACILITY TYPE:
740
ADDRESS:1043 SPARROW LANETELEPHONE:
(707) 386-3888
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Rhodora Lopez, DSP/Designated Staff TIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Rhodora Lopez, DSP/Designated Staff. Administrator Princess Diana Silvero was unavailable during time of visit. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility, all exits were unobstructed, and the facility was found to be at a comfortable temperature. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Staff have current CPR/first aid certifications in file. Fire extinguisher was charged and serviced 08/27/2021. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing. Staff have received refresher training on PPE donning & doffing, Infection Prevention & Control, and Environmental Cleaning to Prevent COVID-19 and other Infectious Diseases from Solano County Public Health on 02/04/2022. During this visit, LPA verified staff COVID-19 vaccination records. LPA verified documentation on N-95 Respirator FIT testing for designated staff (Cal/OSHA requirement) was completed and additional staff have an appointment on 06/21/2022.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/11/2022:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of liability insurance
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
Exit interview conducted with Rhodora Lopez, DSP/Designated Staff, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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