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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320284
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:43:37 PM

Document Has Been Signed on 08/26/2022 12:43 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: 3DATE:
08/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Clodagh Rafferty, On-site LeadershipTIME COMPLETED:
12:45 PM
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On 08/26/2022, Licensing Program Analyst (LPA) Troy Agard conducted a Case Management – incident visit and met with Clodagh Rafferty, On-site Leadership and explained the purpose of the visit. The purpose of the visit was to follow-up on the incident that occurred on 08/21/2022 which resulted in the passing of a client in care.

LPA Agard conducted interviews regarding the incident and the events leading up to it. LPA requested copies of the clients file, staff and client roster, medication administration records, Department of Health Care Services Certificate, progress notes and other pertinent information related to the client and event. Most documents were received. Death certificate and coroner’s report are unavailable at this time.

LPA Agard advised that a subsequent visit regarding the incident may be conducted.

An exit interview was held, and a copy of this report was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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