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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804006
Report Date: 11/18/2024
Date Signed: 11/18/2024 04:04:30 PM

Document Has Been Signed on 11/18/2024 04:04 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRIGHT FUTURE CARE HOMEFACILITY NUMBER:
486804006
ADMINISTRATOR/
DIRECTOR:		ARSENIOANGELES,JOSEFACILITY TYPE:
740
ADDRESS:830 DAFFODIL DR.TELEPHONE:
(707) 724-2299
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Jose Arsenio Angeles, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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At approximately 12:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Jose Arsenio Angeles, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for two (2) and is approved for all non-ambulatory residents. Facility is vendorized with the North Bay Regional Center (NBRC).

At approximately 12:45 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available to residents. LPA advised Administrator to ensure that hand towels are not used in the bathrooms and that paper products are always available to residents. LPA also advised Administrator to ensure that all trash cans in the facility are covered to remain in compliance with regulation. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked, except in the main facility full bathroom, where LPA observed the magnet used to unlock the cabinets stored on the cabinet which contained Draino, Lysol, Goo Gone, Soft Scrub, and other chemicals which pose a risk to residents in care, (see LIC809D). Additionally, LPA advised Administrator to store the facility's red sharps container inaccessible to residents in care and suggested the locked medication cabinet as an option. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. Facility has an internet access device available for resident use. Facility has internet available to residents in care and the phone was tested an operational.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BRIGHT FUTURE CARE HOME
FACILITY NUMBER: 486804006
VISIT DATE: 11/18/2024
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Continued from LIC809...

Facility's fire extinguisher was observed charged and was last serviced 5/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts monthly disaster drills with the most recent drill was conducted 11/2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated 9/2024. LPA observed a supply of PPE, emergency supplies, a first aid kit, flashlights and a back up generator for emergency preparedness. Administrator provided LPA with a copy of the facility's current liability insurance.

At approximately 1:30 PM, LPA reviewed four (4) staff files and four (4) resident files. Four (4) of four (4) staff files reviewed have all of the required paperwork and proof of current First Aid and CPR training. Four (4) of four (4) resident files reviewed have all the required paperwork. Administrator and residents' families coordinates medical and dental visits for the residents and transportation to and from their appointments.

At approximately 3:30 PM, LPA reviewed P&I, medications, and medication records which are maintained and stored in compliance with regulation. Facility has a current bond on file.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal rights were given. Exit interview conducted with Administrator whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 04:04 PM - It Cannot Be Edited


Created By: Julie Florio On 11/18/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BRIGHT FUTURE CARE HOME
FACILITY NUMBER: 486804006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring that magnets for the locks on cabinets containing chemicals and sharps were inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee to submit self certification that they will ensure all of the above mentioned items are stored inaccessible to residents in care to CCL by POC due date 11/19/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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