198320284-8-11-2022-11-AS-DSEA-CH84DQ-20220811190105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320284
Report Date: 08/11/2022
Date Signed: 08/11/2022 07:01:15 PM

Document Has Been Signed on 08/11/2022 07:01 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- SOL		FACILITY NUMBER:	198320284
ADMINISTRATOR:	MAYEH, ELNAZ		FACILITY TYPE:	772
ADDRESS:	1414 SAN VICENTE BLVD		TELEPHONE:	(858) 692-5374
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90402
CAPACITY: 6		CENSUS: 0	DATE:	08/11/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Administrator - Elnaz Mayeh		TIME COMPLETED:	01:45 PM

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On 08/11/2022 Licensing Program Analyst (LPA) Don Senaha conducted an announced visit to the above facility for the purpose of a pre-licensing evaluation. LPA met with Administrator, Elnaz Mayeh and explained the purpose of the visit. During the inspection LPA toured the inside and outside of the facility and verified the address of the location.

An application was submitted to Community Care Licensing Division (CCLD) on 08/04/2022 for a Pre-licensing for a Social Rehabilitation Facility. The total requested capacity is for 6 clients. Facility has a fire clearance dated on 07/14/2022 for 6 ambulatory clients only.

Structure: Facility is a three-story house. The facility has three (3) shared client bedrooms. The first floor consists of the nurse office with a bathroom, therapy office with a bathroom, common bathroom, dining room, group therapy room, kitchen with dining area, living room and access to the garage used for arts and crafts. The garage also consists of extra storage for the pantry food items and two refrigerator/freezers for food storage. The second floor consists of bedroom (1-3). All three (3) bedrooms has its own bathroom. The second floor also consists of a storage area under the stairwell, common bathroom, laundry room and staff office with bathroom. The third floor consists of the library area for clients and staff office area. There is access to the back of the house on both sides of the facility through a gate. The backyard contains a shaded area with seating, bbq area and lawn area for games. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as gardening tools and/or motorized equipment in the front, back and/or side areas of the facility.

Bedrooms: All three (3) client bedrooms have a chair, nightstands, over-head lighting, dressers and/or closets. The closets and drawers comply with the requirement of 8 cubic feet of space.

Continued on 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIGHTFULLY- SOL	FACILITY NUMBER: 198320284
	VISIT DATE: 08/11/2022

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Office: Facility has one (1) office located on the second floor on the south side of the facility used as an administrative space with desk, chairs and cabinets. Staff records and client records are maintained on a digital database (Kipu on emars). Staff office has stairwell leading up to the third floor with more administrative space.

Bathrooms: Facility has 8 bathrooms. There are six (6) bathrooms with working showers and/or bathtubs and two (2) common bathrooms. All bathrooms where observed to have a working toilet, and wash basin.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, bath towels and wash cloths were observed. Facility provides hygiene supplies to clients and LPA observed an adequate supply.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan was observed in the staff office. LPA observed 2 fully charged fire extinguishers throughout the facility. Food menu was posted in on the refrigerator. Emergency contact available on first two floors.

Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the locked cabinet. Food supply was adequately stored. Additional food to come once clients arrive.

Smoke Detectors: Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Detectors are not connected to notify the fire department in the event of a fire. Facility staff will be required to call 911 in the event of an emergency.

Appliances: Stove burners, oven, microwave, washer, and dryer are in working order. There is a large refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Toxins: Locked/stored under the kitchen sink, on the second floor in the laundry room and in the staff office.

Continued on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIGHTFULLY- SOL	FACILITY NUMBER: 198320284
	VISIT DATE: 08/11/2022

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Medications, First-Aid Kit & Book: Area for medication storage is in the nursing office in a locked room and locked in med cart. First aid kit available in the nurse office, kitchen and in the facility vehicle. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. Medications are available for staff administration but inaccessible to clients.

Clients & Staff Files: Records of clients are stored digitally on a database called “Kipu”. Records will be accessible instantaneously when requested at the facility for both clients and staff.

Reading Material, Games, Equipment & Materials: The facility has recreational materials for the client's use.

Pool/Jacuzzi & Pets: There are no bodies of water on the property. No pets observed.

Fire clearance: Fire Clearance was approved on 07/14/2022 for 6 ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick exit during an emergency.

Component III: Conducted at the Pre-Licensing visit, on 08/11/2022 at LIGHTFULLY-SOL. Information was provided about how to operate the facility within substantial compliance with Administrator Elnaz Mayeh.

During the pre-licensing inspection, no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted with Administrator Elnaz Mayeh and a copy of this report has been furnished to the applicant.

Accordingly, LPA Senaha will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the application..

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

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