Brighton Manor

Type of visit: Required - 1 Year

On 3/24/26, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA arrived, introduced self, provided identification, and allowed entrance into facility by Direct Care Staff. Staff contacted Rosanda Anderson by telephone and were unable to make contact with her. Sally Jackson, House Manager contacted by telephone and arrived a short time later to conduct visit with LPA. Facility observed to be clean, odor free, and a comfortable temperature. Currently, there are three (3) residents in care, all residents were present at time of inspection. LPA toured resident bedrooms and observed bedrooms to have required furnishings, LPA observed the window screen in bedroom #2 to be torn and in need of repair. Resident bathrooms toured and observed to have grab bars, shower chair, and non-skid mat available. Fixtures observed operational, water measured at 110 degrees F. Kitchen toured, LPA observed the wall in kitchen nook in need of repair. Facility observed to have a 2-day supply of perishable and 7-day supply non-perishable food available. knives observed to be locked and secured. Outside of facility toured, LPA observed adequate seating and shading available for residents in care. All exits observed to open free of obstruction. The following items were observed during outside tour: a broken, recliner on the back patio, a wood patio set which includes broken chairs near garage, 2 inoperable vehicles parked in driveway. Garage observed to have Christmas decorations, 2 hoyer lifts, washer, dryer, bedrails and miscellaneous items. All items need to be removed or secured. Staff and resident files reviewed. Administrator to submit current LIC 500 and LIC 9020 to Fresno Regional Office no later than Friday, April 3, 2026. All deficiencies observed are being cited on the attached 809-D. Exit interview conducted. A copy of this report provided to House Manger for facility records.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Uncleared staff present in the facility Minor left alone to supervise residents Staff locked resident in bedroom

On 9/25/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to conduct additional interviews and deliver findings. LPA introduced self and stated purpose of visit. Administrator, Rosanda Anderson contacted by telephone and was not available to conduct today's visit. House Manager, Sally Jackson arrived a short time later to conduct visit with LPA. During the subsequent visit, LPA conducted additional interviews and reviewed records. During the course of the investigation, facility was toured, records reviewed, and interviews conducted. This department had insufficient information regarding the allegations listed above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or disprove that the allegations occurred therefore the allegations are UNSUBSTANTIATED. No deficiencies issued during this complaint visit . Exit interview conducted. A copy of this report was provided to Administrator for facility records Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 24-AS-20250811084356

Type of visit: Case Management - Other

On 06/04/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit for the purpose of Health and Safety checks of the residents in care. LPA introduced self, stated the purpose of the visit and allowed entrance by Direct Care Staff. House Manager, Shontina Kelly contacted by telephone and arrived a short time later to conduct Case Management visit with LPA. Facility toured. Facility observed to be clean and a comfortable temperature. LPA observed 2 residents resting in their bedrooms, and 1 participating in activity in the living room, the remain 2 residents were outside in the community. Food supply observed adequate for residents in care. Food pantry observed to be unlocked. All common areas observed to have adequate seating available for residents in care. Facility interior doors on front door, back patio door, and bedroom #4 observed to have key pads in place but door opened without any code. Resident files reviewed. No deficiencies cited during inspection.the state’s words, verbatim · CDSS document, Jun 4, 2025

Type of visit: Office

On 05/20/2025, an informal meeting was held at the Fresno Regional Office. The purpose of the informal meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting. The following were in attendance at this meeting: Licensee, Manjit Chauhan Licensee, Lakhwinder Kaur Administrator, Rosanda Anderson Licensing Program Manager I, Sergiy Pidgirny Licensing Program Manager I, Alexandria Walton Licensing Program Analyst, Melinda Medina During this meeting the following topics were discussed: Licensure of facility Accountability of licensee as a governing body Client Records Plan of Operation Food Service Fingerprint Clearance Fire Clearance In addition, on 04/08/2025 during an annual inspection at Westchester Home on Spruce and on 04/17/2025 during an annual inspection at Brighton Manor, LPA Medina and LPM Walton conducted interviews with staff. During the interviews, consistent statements from staff revealed that S1 has worked in the facilities and S1 has provided care to the residents. LPA checked the facility personnel report in LIS and found that S1 is not cleared to work in the facility. During subsequent visit conducted on 4/17/2025, LPA Medina and LPM Walton were advised that R1 had been moved to another facility. Department was not notified of eviction and R1 was not served with a 30-day eviction. During this meeting, a deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D. An immediate civil penalty is hereby assessed in the amount of $500 for background clearance. Exit interview conducted. Plan of correction was developed and reviewed with the licensee. A copy of this report, civil penalty and appeal rights were discussed and provided to Licensees, Manjit Chauhan and Lakhwinder Kaur.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87335(e)(2) · Plan of correction due date: May 21, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or ** This was not met as evidenced by S1 has been present in the facility and not fingerprint clearedthe state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: S1 to be fingerprinted by 5/21/25 and receive clearance prior to being present in the facility. Plan of correction must be submitted to Fresno Regional Office by close of business on 5/22/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(a) · Plan of correction due date: Jun 3, 2025

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) **This was not met as evidenced by R1 was moved to another facility without being served a 30-day eviction notice.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee and/or Administrator to submit a written plan to understand regulation and submitted to Fresno Regional Office by plan of correction due date.

Type of visit: Case Management - Annual Continuation

On 4/17/25, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) A. Walton conducted an unannounced Annual Continuation visit to facility. LPM and LPA arrived, introduced themselves, stated purpose of visit, and allowed entrance by Caregiver. Designee, Shontina Kelly, contacted by telephone and arrived a short time later to conduct facility visit. During last facility visit, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. Prior to today's inspection, LPM Walton received a Administrator packet for Rosanda Anderson that is currently under review. Upon entry, LPA observed a pin pad on both exterior and interior of door that requires code to unlock front door. . Resident bedrooms toured, residents rooms are observed to have required furnishings, Bedroom #4 observed to have to have a pin pad on both exterior and interior of door that requires a code to unlock door. LPA was unable to open door, bedroom #4 is designated as bedridden bedroom. Resident bathroom toured, water temperature measured at 108 degrees F. Shower/Tub observed to have a non-skid mat and shower chair available. Kitchen toured, LPA observed adequate food supply for residents in care. LPA observed lock on pantry door that needs to be removed. Medication reviewed and observed to be administered as prescribed. During facility tour, LPA asked designee how residents exited facility, designee stated that they just had to push "letter C" on pin pad and pull door open. R1 was unable to open door when asked by LPA. Staff and resident files reviewed during previous inspection on 3/27/2025. All staff files reviewed are missing proper documentation for training. Resident files were incomplete and did not contain, admission agreements, Appraisal/Needs and Services Plans. Outside of facility toured. LPA observed door to back patio has a pin pad on the door that requires a code to exit. At time of inspection, LPA was able to exit without a code. LPA observed shaded area with table and chairs but in need of cleaning. LPA observed several gardening tools in the backyard that need to be locked and secured. LPA observed in an operable car and jet ski on trailer that need to be moved. Designated fire exit in back yard exiting to street observed unlocked but has a double sided dead bolt that needs to be removed. Administrator to submit current copy of Liability insurance, LIC 500, LIC 610, and LIC 9020 to Fresno Regional Office no later than Friday, May, 2, 2025. All deficiencies observed are being cited on the attached 809-D. Immediate Civil Penalty Assessed. Exit interview conducted. A copy of report provided to staff for facility records.the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Required - 1 Year

On 3/27/20205, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA arrived, introduced self, provided identification, and allowed entrance into facility by Direct Care Staff (S1). Staff contacted Rosanda Anderson by telephone to speak with LPA. Per Rosanda, she was not available to meet with LPA. Ryan McClarty, De-Escalation Support staff arrived a short time later to provide staff and resident file for review. LPA observed facility to be clean, odor free, and a comfortable temperature. Currently, there are four (4) residents in care, all residents were present at time of inspection. LPA toured resident bedrooms and observed bedrooms to have required furnishings. Resident bathroom toured and observed to have grab bars, shower chair, and non-skid mat available. Kitchen toured, food supply observed adequate for residents in care, all knives observed to be locked and secured. Staff and resident files reviewed. Due to time constraints, LPA will return at a later time to complete inspection and inspection tool. Deficiencies, if any will be issued at completion of inspection.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Deficiencies

On 3/27/2025, Licensing Program Analyst (LPA) arrived to facility to conduct an an unannounced Annual Required inspection. LPA found the following, staff 1 (S1) on shift is not fingerprint cleared and Staff 2 (S2) on schedule but not present at facility, is fingerprint cleared but not associated to facility. Based on observation, interviews, and records review deficiencies have been cited on the attached 809-D in accordance with the California Code of Regulations, Title 22. Immediate Civil Penalties assessed.the state’s words, verbatim · CDSS document, Mar 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 28, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 2) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement was not met as evidenced by: Based on records review and observation S1 was not finger print cleared to work in the facility which poses an immediate risk to Health and Safety of resident in care. Immediate Civil Penalty being assessed in the amount of $500.00.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator to send S1 to obtain fingerprints and must have fingerprint clearance prior to returning to work. Immediate Civit penalty Assessed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(3) · Plan of correction due date: Mar 28, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement was not met as evidenced by: Based on interview S2 is on the schedule and not associated to facility which poses an immediate risk to Health and Safety of resident in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator to submit fingerprint transfer to Department for S2 prior to S2 returning to work

Type of visit: Case Management - Other

On 11/19/2024, Licensing Program Analysts (LPAs) M. Medina and A. Walton conducted an unannounced Case Management visit to conduct Health and Safety checks on residents in care. LPAs arrived, introduced self, stated purpose of visit, and allowed entrance to facility. Sundae Hill, notified and arrived a short time later to conduct visit with LPA. LPAs arrived to follow up on information provided to Department. Facility observed to be clean, odor free, and a comfortable temperature. Facility observed to a have 2-day supply of perishable and 7-day supply of non-perishable food available. Resident 1 (R1) observed to be having lunch at time of arrival and visiting with family member. Medication and files reviewed. LPAs will return at a later date to address any concerns observed during facility visit. No deficiencies cited during this visit.the state’s words, verbatim · CDSS document, Nov 19, 2024

Allegation investigated: Facility staff do not properly supervise residents after dispensing their medications

On 9/11/24, Licensing Program Analyst (LPA) M. Medina conducted a subsequent unannounced complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Staff, Gina Sadaro contacted by telephone and arrived a short time later to conduct visit. This department investigated the above allegation, during the investigation, LPA toured facility, conducted interviews, and reviewed records. Based on observation during facility tour, LPA observed Staff 3 (S3) dispensed medication into cups and had them placed in front of residents as they were seated at the dining room table and walked away, The preponderance of evidence standard has been met, therefore the allegation: facility staff do not properly supervise residents after dispensing their medication is found to be SUBSTANTIATED. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview was conducted and a plan of correction developed and reviewed. A copy of this report provided to Administrator for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Sep 11, 2024 · control 24-AS-20240510143647

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 25, 2024

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. **This was not met as evidenced by based on observation during facility tour, LPA observed Staff 3 (S3) dispensed medication into cups and had them placed in front of residents as they were seated at the dining room table and walked awaythe state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Prescriptions for medications were transferred to new pharmacy and facility is now utilizing bubble packs. Staff to obtain additional training for medication. Paperwork will be submitted to Department by plan of correction (POC) due date.

Type of visit: Required - 1 Year

On 2/14/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit, and allowed entrance by caretaker. Licensee, Manjit Chauhan contacted by telephone and arrived a short time later to conduct inspection visit. All residents were present during today's inspection. Facility tour conducted with Licensee. Facility observed to be well lit, clean and odor free. All common areas have adequate seating available. Resident bedrooms toured, all bedrooms observed to have required furnishings. Bathrooms toured, showers observed to have non-slid mats, shower chairs, and grab bars. Water temperature during facility inspection measured at 116 degrees F. Kitchen toured, facility observed to have a 2-day supply of perishable food and 7-day of non-perishable food available. Knives observed to be locked and secured in kitchen cabinet. Medication observed to be locked and secured in medication cart. Medication reviewed and observed to have original labels and observed to be administered as prescribed. Smoke detectors and carbon monoxide detector observed operational during inspection. Fire extinguisher present with a service date of 12/18/2023. All chemicals observed to be locked and secured in laundry room. Outside of facility toured. All exits open free of obstruction. No hazards observed. Staff and resident files reviewed and interviews conducted. No deficiencies cited. Exit interview conducted and a copy of report provided for facility records.the state’s words, verbatim · CDSS document, Feb 14, 2024