198320284-11-19-2023-11-AS-DESA-CXQVWE-20231119154750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320284
Report Date: 11/19/2023
Date Signed: 11/19/2023 03:47:56 PM

Document Has Been Signed on 11/19/2023 03:47 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
EL SEGUNDO, 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: 6	DATE:	11/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Spencer Roesch, Primary Therapist		TIME COMPLETED:	04:40 PM

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On 11/19/2023 at 12:19 pm Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA met with S#1 and discussed the purpose of the visit. During the inspection LPA toured with S#2 the inside and outside of the facility were verified the address of the location with S#2. The facility is a Social Rehabilitation Facility. The facility has six (6) clients.

Facility has a fire clearance dated on 07/14/2022 for 6 ambulatory clients only. LPA confirmed fire drill was on 11/13/2023. 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 Social Rehabilitation Facility (SRF) facility is short term crisis residential, approved for (6) ambulatory.
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. 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. Facility Evaluation report Continued on 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

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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Document Has Been Signed on 11/19/2023 03:47 PM - It Cannot Be Edited

Created By: David Espana On 11/19/2023 at 03:00 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: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81066(a-d)

(a)An employee work schedule shall be developed at least monthly, shall be displayed conveniently for employee reference, and shall contain the following information for each employee: (1) Name; (2)…Job title; (3)Dates, days and hours of work; and (4) Days off. (b) Staff training as required by Section 81065(r) shall be documented. Documentation shall include the subject of the training, who conducted the training, and the date(s) of the training. (c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (1)Employee's full name. (2)…. (d) Personnel records shall be maintained for all volunteers and shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA España and S#1 and S#2 observed that staff 1, 2, and 3 are missing LIC501, LIC503, LIC508, TB, LIC9052, TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The administrator/licensee agreed to address all missing LICs forms and TB for staff for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do not reoccur at the facility. The administrator of record shall update the resident's/staff's in-services plans within 30 days david.espana@dss.ca.gov.

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:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIGHTFULLY - SOL	FACILITY NUMBER: 198320284
	VISIT DATE: 11/19/2023

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

The two (2) telephone, which is a land line work or operational. 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. 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. 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. 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.

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. 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. The facility has recreational materials for the client's use. There are no bodies of water on the property. No pets observed. 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. Facility Evaluation report Continued on 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIGHTFULLY - SOL	FACILITY NUMBER: 198320284
	VISIT DATE: 11/19/2023

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All mandated inspection control posters were posted. There were deficiencies observed during today's inspection.

Based on observation, interview, record review, the licensee did not comply with the section cited on today's visit. LPA España and S#1 and S#2 observed that staff #1, #2, and #3 are missing LIC501, LIC503, LIC508, TB, LIC9052, which poses/posed a potential health, safety or personal rights risk to persons in care.

An exit interview was conducted with Staff #1 (S#1) and a hard copy of the report with appeal rights was furnished.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

LIC809 (FAS) - (06/04)

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