BRIGHTON MANOR

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above: LPA observed the window screen in bedroom #2 to be torn and in need of repair. LPA observed the following 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 that need to be secured. LPA observed the wall in kitchen nook in need of repair near. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2026 Plan of Correction All items from back yard will that are broken will be removed, garage will be cleaned and items will be either removed or properly securely. Registered owner of vehicles will be contacted for removal and information submitted to Fresno Regional office.

Official classification

Type A

Official code

87335(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 cleared

Official 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.

Deadline recorded: May 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: Jun 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, LPA observed a pin pad on both exterior and interior of door that requires code to unlock front door, pin pad on interior of door to exit to back yard, and on both exterior and interior of bedroom #3 designated as bedridden. LPA also observed a double sided dead bolt on fire exit from back yard to street that must be removed which is which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction Designes stated that pin pad will be removed from all interior doors of facility. 2-sided dead bolt on designated fire exit from backyard to street will be removed.

Official classification

Type A

Official code

1569.618(c)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation during facility inspection, the licensee did not comply with the section cited above, R2 and R3 designated as 1:1 in care plan, there was only 1 staff present for four residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction Designee to update schedule and have adequate staffing to provide proper care and supervision of residents in care.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as resident files reviewed did not contain care plans which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction All resident care plans are being updated and will be placed in files.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed gardening tools in the back yard, and an inoperable car and jet ski on trailer that need to be movedi which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Gardening tools to be stored and locked after use. Inoperable care and jet ski on trailer to be moved

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above review of resident records were incomplete, missing and or missing documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Resident files to be reviewed and ensure that all required documents are in file

Official classification

Type B

Official code

1569.625(c)

Regulation authority

HSC

What the official deficiency says

(c) the training shall include, but not limited to, the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above staff files are lacking documentation to show annual required training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Staff files to be reviewed and ensure that all staff have required annual training.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

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

Deadline recorded: Mar 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

Administrator to submit fingerprint transfer to Department for S2 prior to S2 returning to work

Deadline recorded: Mar 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 away

Official 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.

Deadline recorded: Sep 25, 2024. A deadline is not proof that correction was completed.