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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804163
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:25:37 PM

Document Has Been Signed on 07/13/2023 01:25 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRIGHT LIFE CARE HOME IIIFACILITY NUMBER:
486804163
ADMINISTRATOR:SILVERIO, PRINCESS DIANAFACILITY TYPE:
740
ADDRESS:618 PERIWINKLE DRTELEPHONE:
(925) 699-3610
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 0DATE:
07/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Princess Diana Silverio
Licensee, Arnel Silverio		TIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Farhaan Sarangi and Carol Folwer arrived announced at Bright Life Care Home III for the purpose of conducting a Pre-Licensing Inspection. LPA was greeted at the door by Princess Diana Silverio and Arnel Silverio. The facility is approved for 4 non-ambulatory residents with 0 bedridden and 0 ambulatory. Administrator presented the LPA with the Administrators Certificate for Residential Care for the Elderly (Standard Certificate #6048110740 with an expiration of 09/11/2024). First Aid Certificate was observed for the Administrator that expires on February 3, 2025.

LPAs, Administrator and Licensee toured the one story facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguishers were found to be last charged on August 2022. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature measured at 112 degrees in 3 of 3 residents bathrooms and is within Title 22 regulations. Sample food menu was observed on the refrigerator. Activities Menu was observed during the Pre-Licensing Inspection. LPA observed sufficient perishable and non-perishable foods located in the refrigerator and pantry. There were ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Resident records, personnel records and medications will be locked and in separate cabinets which are inaccessible to residents in care. Hazardous items and toxins are kept locked and inaccessible to residents in care. Facility has a first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is an outdoor space for activities with a shaded area for residents in care. During the Pre-Licensing inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. All staff will be trained in the Emergency Disaster and PPE training. Emergency Disaster plan was discussed with the Administrator. LPA was advised that the facility is in the process of obtaining a Emergency Generator. LPA and Licensee observed an updated facility sketch. LPA requested the Licensee to send over the most updated facility sketch to the Centralized Applications Bureau (CAB) Analyst.(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BRIGHT LIFE CARE HOME III
FACILITY NUMBER: 486804163
VISIT DATE: 07/13/2023
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Component III was waived due to already being licensed.

Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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