BRIGHT STAR ASSISTED LIVING

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as during tour LPA tested the hot water temperature and measurements were between 125.1-141.1 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2026 Plan of Correction During tour Administrator lowered the hot water temperature to the water heaters in the areas that meausuerd outside the range (near D8, C2, B4). Administrator to create a waterlog for the next 3 days and measure water temperature begining tomorrow 8/26/26 and ending 8/28/26. water to be measured morning/afternoon/evening and all measurments must be within the required range a copy of the waterlog must be emailed to LPA no later than 8/31/26.

Official classification

Type B

Official code

87412(c)(2)(D)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 2. If the educational hours/units are obtained through an accredited educational institution, documentation shall include a copy of a transcript or official grade slip showing a passing mark. 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 in 3 of 6 Staff files reviewed during visit were missing proof of completed training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2026 Plan of Correction Administator/Licensee to provide LPA with proof of completion of the required trainings via email for the 3 staff that were missing their training (S3-S5) by POC due date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in, as Resident #4 (R4) has a half bed rail without a physician's order on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction The administrator is to ensure that physicians’ orders are kept in Resident #4 (R4’s) file that has bed rails at all times. The administrator is to either obtain a physician's order for the bed rails to the LPA or remove them if unnecessary submit a plan by the POC due date.

Official classification

Type B

Official code

80086(a)

Regulation authority

CCR

What the official deficiency says

80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This standard was not met as evidence by: Administrator/Licensee failed to report to the department of renovations that were being done to the facility dining area. Renovations began on approximately 11/13/24 and licensing became aware of remodel to dining due to a complaint that was generated on 12/9/24.

Official plan of correction

Administrator/Licensee to submit an Incident Report to LPA by POC due date that discloses all renovations that have been done when it started, why it stopped and when it is schedule to end. Incident report can be emailed to LPA tena.herrera@dss.ca.gov

Deadline recorded: Dec 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 Staff #1 (S1) was missing their First-Aid Certificate, Administrator confirmed that this staff provides care to residents as a caregiver, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Administrator is aware that staff must complete First-Aid training prior to providing care to residents, Administrator will have S1 complete training and send LPA a copy of the valid First-Aid certificate to LPA by POC due date via email (tena.herrera@dss.ca.gov).

Official classification

Type B

Official code

87458(b)(5)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. 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 #1 (R1) file was missing their Physician Report, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Administrator to either find the Physician Report they have for R1 or email a new (updated) Physician Report for R1 to LPA via email by POC due date (tena.herrera@dss.ca.gov)

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 the liability insurance was observed to have the required $1,000,000 coverage for injury to residents and guests but only has $2,000,000 of total annual aggregate coverage which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2023 Plan of Correction Licensee to update the Liability Insurance Policy to meet the required coverage and email a copy of new Certificate of Liability Insurance to LPA via email by POC due date.

Official classification

Type B

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and conversation with Administrator, the licensee did not comply with the section cited above in 2 out of 2 stairwells did not have the required evacuation chairs, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2023 Plan of Correction Administrator stated they will purchase the required evacuation chairs to meet the regulation and place them at each stairwell. Administrator to email a copy of the receipt of purchase to LPA by POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA tested water temperature in Dining Hall resident restrooms and upstairs restrooms, temperature readings in 4 of the restrooms read 122.0, 132.4, 134.0 and 138.2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2023 Plan of Correction Administrator to create a water temperature log for the next 5 days and document the date, time, and water temperature reading to ensure that water temperature is maintained within the required regulation. Water temperature should be tested 3 times daily, morning, day, evening and must be tested throughout the facility restrooms not just one restroom. This log is to be sent to LPA via email by 10/27/23. *water temperature was lowered during visit*