191222083-8-24-2021-29-AS-EPEI-C67RDT-20210824125628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222083
Report Date: 08/24/2021
Date Signed: 08/24/2021 12:57:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LIGHTHOUSE, THE		FACILITY NUMBER:	191222083
ADMINISTRATOR:	GABRIELA VISOVAN		FACILITY TYPE:	740
ADDRESS:	10406 MAGNOLIA BLVD.		TELEPHONE:	(818) 766-3764
CITY:	TOLUCA LAKE	STATE: CA	ZIP CODE:	91601
CAPACITY:	49	CENSUS: 23	DATE:	08/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	GABRIELA VISOVAN		TIME COMPLETED:	01:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:40 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by Administrator, GABRIELA VISOVAN. This annual had a specific emphasis on infection control practices and procedures. At 10:50 a.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. OUTDOOR SPACE: At 11:05 a.m., LPA observed the patio, which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction. KITCHEN: At 11:03 a.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:05 a.m., LPA observed staff preparing food in the kitchen. Medications and first aid kits are located in a locked medication room. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 10:52 a.m., LPA observed over the counter medication in resident room #1. The staff removed these items upon observation. At 11:44 a.m., hot water measured at 113.3-Degree Fahrenheit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIGHTHOUSE, THE	FACILITY NUMBER: 191222083
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there were over-the-counter medications accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/24/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. The items were removed upon observation. Plan of Correction met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIGHTHOUSE, THE	FACILITY NUMBER: 191222083
	VISIT DATE: 08/24/2021

NARRATIVE

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Continued from LIC 809.

Common Areas: LPA observed common area to be relatively clean and properly furnished. At 10:53 a.m. LPA observed the fire extinguisher to be fully charged and last serviced on 02/03/2021.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 11:00 a.m. - 12:00 p.m., LPA conducted Infection Control mitigation module with Administrator.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Report issued and a copy of the report and appeal rights was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

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