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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804163
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:03:42 PM

Document Has Been Signed on 06/07/2024 03:03 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 LIFE CARE HOME IIIFACILITY NUMBER:
486804163
ADMINISTRATOR/
DIRECTOR:		SILVERIO, PRINCESS DIANAFACILITY TYPE:
740
ADDRESS:618 PERIWINKLE DRTELEPHONE:
(925) 699-3610
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Sharnell Davis, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 12:40 PM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by Sharnell Davis, Administrator. The facility is a single story home licensed for four (4) non-ambulatory residents and a hospice waiver capacity of two (2). The facility currently provides care for 4 residents and there are no resident's under hospice care at this time.

At approximately 12:50PM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected ,There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room and kitchen. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 117 and 120 degrees F at four of four faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Five out of five interconnected combo Smoke/Carbon monoxide detectors were present inspected and found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways.


Continued on LIC809-Ca
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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 LIFE CARE HOME III
FACILITY NUMBER: 486804163
VISIT DATE: 06/07/2024
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Continued on LIC809

Facility provides art therapist, nutritionist, and activity director paid by facility to ensure clients needs are met. Facility offers a designated activity room in the garage.

Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Resident was observed interacting with staff in bedroom and living room. Three of four residents were home. One of four residents was at day program. One of four residents was doing artwork and resident's mother was visiting. One of four residents was relaxing in the living room watching television. One of four residents was relaxing in their room. LPA observed staff checking on, engaging, and caring for residents often.

At approximately 1:40PM, LPA reviewed Four of four resident records which were all found to be well organized, thorough and contained the required documentation. At approximately 2:15 PM, LPA reviewed six out of eleven staff records which were all found to be well organized, thorough and contained the required documentation. Medication records are thorough and contained physician's orders for each resident. P&I is not commingled.

Administrator Administrator Certification is current and expires on 03/16/2026.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 500 Personnel Summary
LIC 400 Cash Affidavit
LIC 9020 Register of Facility Client’s/Resident's
Liability Insurance
Surety Bond

No citations issued during today’s visit.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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