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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320284
Report Date: 09/02/2022
Date Signed: 09/02/2022 03:48:02 PM

Document Has Been Signed on 09/02/2022 03:48 PM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LIGHTFULLY - SOLFACILITY NUMBER:
198320284
ADMINISTRATOR:MAYEH, ELNAZFACILITY TYPE:
772
ADDRESS:1414 SAN VICENTE BLVDTELEPHONE:
(858) 692-5374
CITY:SANTA MONICASTATE: CAZIP CODE:
90402
CAPACITY: 6CENSUS: 0DATE:
09/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Elnaz Mayeh TIME COMPLETED:
03:45 PM
NARRATIVE
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On 09/02/2022, Licensing Program Analyst (LPA) Troy Agard and Licensing Program Manager (LPM) Stephanie Cifuentes conducted a Case Management visit to the above facility. The purpose of the visit was to issue citations observed during a case management visit on 08/26/2022. LPA & LPM met with Elnaz Mayeh, Administrator and the purpose of the visit was explained.

On 8/26/2022, LPA Agard initiated a visit in response to a death report received by the Regional Office on 08/22/2022. The death report indicated client #1 passed away at the facility. LPA Agard gathered records for client #1, conducted interviews and conducted a tour of the physical plant. Based on a review of the records obtained and interviews conducted the following deficiencies were found.

Clients have been relocated to Lightfully - Sunrise temporarily

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code HSC §1548 (e) - (f) “For a violation that resulted in death” as defined in Section 243 of the Penal Code.

Civil Penalties Assessed

Exit interview conducted, appeal rights were discussed, and a copy of this report was provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/02/2022 03:48 PM - It Cannot Be Edited


Created By: Troy Agard On 09/02/2022 at 11:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIGHTFULLY - SOL
FACILITY NUMBER: 198320284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2022
Section Cited
CCR
81019(e)(2)

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance… This requirement is not met as evidence by:
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Licensee to ensure staff 1-4 obtain a criminal record clearance or exemption and submit documentation to LPA Agard by POC due date.

An immediate civil penalty assessed.
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Based on observation and records reviewed the licensee failed to ensure a request to transfer criminal record clearances was submitted to the licensing agency. This poses an immediate Health & Safety risk to clients in care.
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Type A
09/03/2022
Section Cited
CCR81065(f)(5)

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Personnel Requirements
All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.This requirement was not met as evidence by:
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Licensee shall provide staff training in emergency procedures and submit documentation to LPA Agard by POC due date.


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Based on interviews and records reviewed the licensee failed to ensure client #1 received timely medical treatment when client became ill on August 20th 2022. This poses an immediate heath & safety risk to clients in care.
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/02/2022 03:48 PM - It Cannot Be Edited


Created By: Troy Agard On 09/02/2022 at 12:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIGHTFULLY - SOL
FACILITY NUMBER: 198320284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2022
Section Cited
CCR
81078(a)

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Responsibility for Providing Care & Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidence by:
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Licensee shall ensure staff have access to all areas of the facility and submit documentation to LPA Agard by POC due date.
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Based on interviews conducted the licensee failed to ensure staff had access to all areas in the facility. This poses a health & safety risk to clients in care.
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Type B
09/06/2022
Section Cited
CCR81061(a)

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Reporting Requirements
(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. This requirement was not met as evidence by:
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Licensee shall complete and submit an LIC 624 to LPA Agard by POC due date.
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Based on observation and interviews conducted, clients have been relocated to Lightfully - Sunrise temporarily. A plan of intention was not submitted via a LIC 624 prior to relocation.
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022


LIC809 (FAS) - (06/04)
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