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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804275
Report Date: 12/10/2024
Date Signed: 12/10/2024 10:38:06 AM

Document Has Been Signed on 12/10/2024 10:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LIGHTHOUSE, THEFACILITY NUMBER:
126804275
ADMINISTRATOR/
DIRECTOR:		GILBERT, DAVIDFACILITY TYPE:
735
ADDRESS:6253 BERRY LANETELEPHONE:
(530) 300-4238
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 16CENSUS: 0DATE:
12/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:David GilbertTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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At approximately 8:10AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant David Gilbert and toured the facility. The Facility is a 8-bedroom, 3-bathroom, single story house. Fire extinguishers were mounted and charged. Smoke detectors were tested and in working order. Carbon monoxide detector was present and operational. There was a locked area for medications and several for toxins and cleaning supplies. Beds were made with appropriate linens. Resident rooms contained furniture as required in all rooms. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents. Facility has two offices with secure storage for files.

A fire clearance for this facility has been granted for 14 ambulatory and 2 non-ambulatory residents.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.

The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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