198320284-8-28-2024-11-AS-HENZ-D8KV9Q-20240828161443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320284
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:15:08 PM

Document Has Been Signed on 08/28/2024 04:15 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	LIGHTFULLY - SOL		FACILITY NUMBER:	198320284
ADMINISTRATOR/ DIRECTOR:	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:	08/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:29 AM
MET WITH:	Director Katherine Bergerson		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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On 08/28/2024 around 10:30 am Licensing Program Analysts (LPAs) Hollie Enriquez and Regina Cloyd conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with the Katherine Bergerson Director the purpose of today’s visit was explained. The facility is licensed to operate for six (6) ambulatory adults and elderly individuals. The facility does not serve clients with Restricted Health Care Conditions.

The facility is a three-story home located in a residential neighborhood on a main boulevard. The property consists of the following: The First Floor houses the garage activities and storage, medication room, therapy room, kitchen, 1 activity/lounge area and 1 large arts activities area, a living room, dining room, 1 common bathroom, 2 staff bathrooms. The Second Floor consists of the staff office and supply room, the three (3) client bedrooms each with furnishings for two (2) clients and each with private client bathroom, a laundry room, and a common bathroom. The Third Floor is a small loft with a sitting/lounge area with a balcony.

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SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 08/28/2024 04:15 PM - It Cannot Be Edited

Created By: Hollie Enriquez On 08/28/2024 at 02:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIGHTFULLY - SOL	FACILITY NUMBER: 198320284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81077.3(a)

Care for Clients who Lack Hazard Awareness or Impulse Control

(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations of zip ties locking the second floor balcony doors and side exterior gates locked, interview with Director that door and side gates are always locked and record review that no Exceptions are on file, the licensee did not comply with the section cited above which poses a potential safety and personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Director agrees to unlock the side gates and keep the gates unlocked. Director agrees to remove the zip ties from the second floor balcony and allow acces to open the doors. Director agrees not to lock doors and gates unless CCL approves a request for an exception.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Hollie Enriquez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIGHTFULLY - SOL	FACILITY NUMBER: 198320284
	VISIT DATE: 08/28/2024

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LPA Enriquez conducted a records review of six (6) client records. LPA Cloyd conducted a records review of five (5) staff records. All client & staff records were complete. LPAs reviewed the facility Emergency/Disaster Plan and Infection Control Plans and both plans were current and in compliance with Title 22. LPA Cloyd reviewed two (2) MARs and Medications and no issues were observed.

At 11:27 am LPA Enriquez and Director Katherine Bergerson toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured as follows: Common Bathroom 115.3 degrees F, and bedroom private bathroom between 114.7-115.7 degrees F).

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SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIGHTFULLY - SOL	FACILITY NUMBER: 198320284
	VISIT DATE: 08/28/2024

NARRATIVE

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins, knives and other sharp objects were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

At today's visit LPAs observed the following deficiencies were not in compliance:

-On 08/28/2024 at 11:53 am, LPA Enriquez observed that the second-floor balcony doors had zip ties that prevented the door from opening. Interview with Director indicated that the doors are tied and remain locked. At around 12:10pm, LPA Enriquez observed that the side gate was locked and interview with Director indicated that the side gates are always left locked. At 3:35 pm, Director unlocked side gates and removed balcony door zip ties. LPA Enriquez observed that both the doors and gates were unlocked and accessible to clients in care. Proof of Correction cleared and updated. Director agrees to submit a letter to CCLD requesting for an Exception to lock any doors or gates in the facility and agrees to keep the doors and gates unlocked until CCLD provides a response to the request.

Deficiencies Cited Under California Code of Regulations Title 22, Division 6.

Exit interview conducted and a copy of the appeal rights were given.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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