Brightwater Guest Home 3

Type of visit: Required - 1 Year

On 05/16/2026, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced annual inspection visit and met with the Administrator, Irene Formentera. The purpose of the visit was explained and the LPA was allowed entry to the facility. This facility is licensed to serve 6 bedridden adults ages 60 and above. 5 bedrooms are cleared for bedridden residents. The facility is approved to admit or retain 2 residents on hospice. A total of 6 residents are currently residing in this facility. The LIC999 Facility Sketch (Floor Plan) that is on file in El Segundo Regional Office depicts the following: a one-story house with 5 resident bedrooms, 1 staff room, 3 bathrooms, 1 attached garage, and a great room with kitchen and living room. Facility Layout (LPA Observations): is a one-story house located in a residential street. The home consists of 6 resident bedrooms (resident bedroom 6 is designated as the staff in the LIC999); 3 full bathrooms; 1 staff room walls are not touching the ceiling (this room is not depicted on the LIC999); 1 great room which includes the kitchen area, dining table, and living room area; 1 attached garage; and 1 backyard patio area with shaded seating. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher near the kitchen area. There is a landline phone in the kitchen area. Living Room/Community Indoor Space: There is a videoconferencing device, and games/activity work for residents in the living room area. There are couches and chairs for residents to sit at. Resident Bedrooms: 6 out of 6 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Room 1 has a non-ambulatory resident who uses a wheelchair and their room has several items on the floor which makes it difficult to maneuver around Bathrooms: Toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. The hot water temperature measured 129.2 Fahrenheit. There was a leaky shower faucet in bathroom 1. Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Medications were reviewed along with their Administration Records (MARs). Garage: has several items which makes it difficult to maneuver around. Miscellaneous: Documents are posted as mandated. Last disaster drill was conducted on 04/15/2026. The last Annual Fire Inspection was completed by the Torrance Fire Department on 04/14/2026. First aid kit is fully stocked with manual. Liability Insurance is current and it expires on 11/01/2026. The facility has a current Infection Control Plan and Emergency Disaster Drill. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed, 3 out of 5 resident records did not have requires documentation. Resident 2 does not have an updated Medical Assessment and does not have their Home Health Folder. Resident 4 does not have doctors order for half bed rail. Resident 5 does not have an updated Medical Assessment. Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.the state’s words, verbatim · CDSS document, May 16, 2026

Type of visit: Case Management - Other

On 09/25/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit to the above-named facility and met with Caregiver, Rosemarie Masancay. The purpose of the visit was explained and the LPA was allowed entry to the facility. This facility is licensed to serve 6 bedridden adults ages 60 and above. 5 bedrooms are cleared for bedridden residents. The facility is approved to admit or retain 2 residents on hospice. A total of 5 residents are currently residing in this facility. The Annual Licensing Fees are current. The LIC999 Facility Sketch (Floor Plan) that is on file in El Segundo Regional Office depicts the following: a one-story house with 5 resident bedrooms, 1 staff room, 3 bathrooms, 1 attached garage, and a great room with kitchen and living room. Facility Layout (LPA Observations): is a one-story house located in a residential street. The home consists of 6 resident bedrooms (resident bedroom 6 is designated as the staff in the LIC999); 3 full bathrooms; 1 staff room walls are not touching the ceiling (this room is not depicted on the LIC999); 1 great room which includes the kitchen area, dining table, and living room area; 1 attached garage; and 1 backyard patio area with shaded seating. Outside Grounds: were toured no bodies of water were observed and walkways around the home were clear of hazards Resident Bedrooms: 5 out of 5 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. LPA reviewed resident records alongside Administrator, Jehn Demafelix. LPA informed the Administrator that resident records were incomplete. At around 1:00 PM, the Administrator left the facility and informed LPA that they will bring the requested records to the facility. At around 3:00 PM, Administrator, Irene Formentera arrived at the facility but did not bring the requested documentation for example, Resident 1’s (R1) Home Health Care Plan and R1’s to R5’s (Resident 5) pending doctors orders for bed rails. 5 resident records were reviewed and 5 out of 5 resident records were incomplete. Technical violations are being provided regarding: Physical Plant, Home Health, and Postural Supports. A deficiency is being provided regarding maintaining current and accurate records in the facility. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Irene Formentera.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 7, 2025

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Based on observation and record review the licensee did not comply with the section cited above. In R1's to R5's records were incomplete. R1 did not have: a Home Health Care Plan; a Doctor’s Order for Hoyer Lift & Half Bedrails. R2 and R3 did not have a Doctor’s Order for Half Bedrail. R4 did not have a Doctor’s Order for Half Bedrail & Hoyer Lift. R5 did not have a Doctor’s Order for Full Bedrail & Oxygen Machine.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: The Administrator Irene Formentera has agreed to email the pending records for Resident 1 (R1) to Resident 5 (R5) to Socorro.Leandro@dss.ca.gov.

Type of visit: Case Management - Other

On 06/05/2025 around 9:10 AM, the Department of Social Services (DSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit and met with Caregiver Rosemarie Masancay and the purpose of the visit was explained. LPA was granted entry to the facility. A total of 4 residents are currently residing in this facility. The department conducted a tour of the facility. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator Irene Formentera.the state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Irene Formentera, Administrator and the purpose of the visit was discussed. The facility is licensed to serve 6 non- ambulatory residents. All 5 rooms are cleared for bedridden fire clearance. Facility approved to admit or retain 2 residents on hospice. The facility is 8775 compliant. Currently 2 resident has dementia, 1 resident receiving home health and 2 resident on hospice care services. The facility does not handle any of the residents’ money. This home is a single story home consisting of: (6) resident bedrooms, (1) staff room (3) Full bathroom, , living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. 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, water temperature measured between 110F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. During todays visit LPA did not observe any deficiencies. Exit interview with Administrator Irene Formentera.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Case Management - Health Checks

On 12/10/2024 around 9:50 AM, the Department of Social Services (DSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced case management visit and met with Caregiver, Sherlyn Anoche. The purpose of the visit was explained to the Administrator, Irene Formentera. A total of 5 residents are currently residing in this facility. The department conducted a tour of the facility and gathered facility records. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the Annual inspection. LPA met with Irene Formentera , Area Manager and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents. All 5 rooms are cleared for bedridden fire clearance. Facility approved to admit or retain 2 residents on hospice. resident. Facility is 8775 compliant. 2 resident has dementia, 2 resident receiving home health and 2 resident on hospice care services. The facility does not handle any of the residents’ money. This home is a single story home consisting of: (6) resident bedrooms, (1) Full bathroom, 3 half restroom, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. 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, water temperature measured between 112F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA did not observe any deficiencies during todays visit. An exit interview was conducted and a copy of Report providedthe state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Resident sustained pressure injuries while in care. Staff did not follow resident's hospice care plan. Staff did not meet resident's incontinence needs. Staff did not notify responsible party of resident's change in condition. Licensee does not maintain facility clean and sanitary. Staff did not assist resident with grooming. Staff did not assist resident with bathing.

On 03/14/24, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Renel Cabral, Facility Manager. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by LPA Perry Scott on 02/16/23. A subsequent visit was completed by LPA Perry Scott on 03/14/24. LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S3) and residents (R1-R4). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, Hospice information, ID/Emergency information, Physicians report, Doctor’s notes, Preplacement Appraisal information, Daily Assessment & Turning and Repositioning logs, and Patient visit documentation logs were obtained from the facility. Report continued on LIC-9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Resident sustained pressure injuries while in care. The details of the complaint alleged that the facility did not regularly rotate the resident every two hours as ordered in the resident's hospice plan, causing the resident to develop multiple pressure injuries on the back, bottom, arms, and legs. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Resident sustained pressure injuries while in care because the facility failed to rotate the resident every two hours. All staff stated that the resident was turned every two hours and repositioned. S1 stated that “all staff have had in-service training in how to care for hospice residents and pressure injury care was provided to this resident. Also, the resident had a history of skin breakdown prior to moving into our facility as reported in the LIC602, dated 07/07/2022”. S2 stated that “the resident’s skin was brittle and bruised easily”. LPA reviewed the Turning and Repositioning logs and the Patient Visit Documentation log from hospice that corroborates their account that the facility was following the care plan for the resident. LPA reviewed the Physician’s report (LIC602) dated 07/07/2022, that reports the resident has a history of skin condition or breakdown and is very sensitive. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Resident sustained pressure injuries while in care. Residents stated that they did not have any problems with neglect from the facility. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Resident sustained pressure injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur because the facility failed to follow the hospice care plan for the resident, therefore the allegation is Unsubstantiated. Report continued on LIC9099-C Allegation # 2- Staff did not follow resident's hospice care plan. The details of the complaint alleged that the facility did not follow the hospice care plan for the resident that led to the resident developing pressure injuries. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not follow resident's hospice care plan. All staff stated that the resident was turned every two hours and repositioned, and that the facility was adhering to the resident’s care plan. LPA reviewed the Turning and Repositioning logs and the Patient Visit Documentation log from hospice that corroborates their account that the facility was following the care plan for the resident. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not follow resident's hospice care plan. Residents stated that they were happy with the care and supervision being provided to them. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff did not follow residents’ hospice care plan. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 3- Staff did not meet resident's incontinence needs. The details of the complaint alleged that the facility did not change the residents’ diaper regularly. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not meet resident's incontinence needs. All staff stated that all residents are monitored for issues of incontinence every two hours and are changed as necessary throughout the day. Staff stated additionally that some are changed more often than others according to their need and that it is noted in the changing log. LPA reviewed the changing log and found that the facility was changing the resident regularly. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not meet resident's incontinence needs. Residents stated that the staff are attentive to their incontinence issues and are changed when needed. Report continued on LIC9099-C Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff did not meet resident's incontinence needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 4- Staff did not notify responsible party of resident's change in condition. The details of the complaint alleged that the facility did not notify the responsible party of a change in the resident’s condition. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not notify responsible party of resident's change in condition. All staff stated that when a resident has a change in their condition the family is notified along with the hospice agency, and their Primary Care Physician. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not notify responsible party of resident's change in condition. Residents stated that they are happy with the staff and the care that they are getting from the facility. Based on interviews there is insufficient evidence to support the allegation that Staff did not notify responsible party of resident's change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 5- Licensee does not maintain facility clean and sanitary. The details of the complaint alleged that the residents’ room was dusty and unclean. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Licensee does not maintain facility clean and sanitary. Staff stated that the facility is cleaned three times a day. At breakfast, lunch, and dinner. They state that they clean the room first, do the laundry, and clean other areas of the house throughout the day. Report continued on LIC9099-C LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Licensee does not maintain facility clean and sanitary. The residents stated that the facility is never dirty or unsanitary. LPA observed the facility to be clean and maintained in accordance with Title 22 regulations. Based on interviews and observations there is insufficient evidence to support the allegation that Licensee does not maintain facility clean and sanitary. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 6- Staff did not assist resident with grooming. The details of the complaint alleged that the facility failed to wash the resident's face, resulting in the resident contracting conjunctivitis in one of her eyes. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not assist resident with grooming. All staff state that the residents’ hygiene needs are taken care of daily. S2 stated “We groom and bathe in the morning and evening. Home health nursing assistant and caregivers are in charge of doing both. It depends on the time. When they’re not here we do it”. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not assist resident with grooming. Residents stated that the staff does assist with grooming and bathing and that they are happy with the care and supervision given. Based on interviews there is insufficient evidence to support the allegation that Staff did not assist resident with grooming. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 7- Staff did not assist resident with bathing. The details of the complaint alleged that the facility did not clean nor bathe the resident. On 02/16/23, from 09:30am-02:00pm, LPA interviewed staff (S1-S3) and residents (R1-R4) regarding the allegation. 3 of 3 staff denied the allegation that Staff did not assist resident with bathing. Report continued on LIC9099-C All staff stated that all residents are groomed, changed, and bathed daily and that all staff are responsive to the personal care needs of its residents. LPA interviewed R1-R4 about the allegation and all that were interviewed denied the allegation that Staff did not assist resident with bathing. Residents stated that the staff does assist them with grooming and bathing. The residents further stated that are happy with the care and supervision provided by the staff. Based on interviews there is insufficient evidence to support the allegation that Staff did not assist resident with bathing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Renel Cabral, Facility Manager, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 11-AS-20230210142856