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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800912
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:04:51 PM

Document Has Been Signed on 08/29/2023 05:04 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEACONLIGHT CARE HOMEFACILITY NUMBER:
216800912
ADMINISTRATOR:HYPPOLITE, WALLYFACILITY TYPE:
735
ADDRESS:1468 SOUTH NOVATO BLVDTELEPHONE:
(415) 756-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Wally Hyppolite, Licensee/Administrator TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required inspection to this facility and was welcome by Licensee/Administrator Wally Hyppolite. There are 6 Clients residing in the facility, during today’s inspection 2 were attending their day programs, one was visiting family, one was at work, and two clients were at the facility.

LPA toured the facility on 8/29/2023 at 12:30 PM with Licensee Wally Hyppolite; facility was found to be at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. During tour of facility on 8/29/2023 at 1:05 pm LPA observed facility ceiling in bathroom with water damage (see pic) & floor in office & walls and floor in entry way to have dirt and dabret covering (see pics), and client bedrooms 3 & 4 to be picked up of excessive clutter as it posses a fire hazard (see pics) (see LIC 809-D) Fire Extinguisher was found to be last charged on 5/1/2023 at the time of the visit. Facility smoke detectors and carbon monoxide are hard wired though out and were found to be functioning properly at the time of the visit. Hot water temperature measured between 118.9 degrees F & 125.6 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 3 client’s bathroom while touring facility on 8/29/2023 at 12:50 PM (see LIC 809D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room and kitchen; although during today’s inspection on 8/29/2023 at 1:10 PM LPA observed cabinet in laundry room and kitchen unlocked and cleaning supplies in 2 unlocked bathroom cabinets (see pics). Dangerous items were stored accessible to develop disabled clients in the kitchen at the facility on 8/29/2023 at 1:15 pm (see pics)(see LIC809-D).

There was a supply of cleaners, hygiene products and paper products available for clients. Bathrooms designated for clients at the facility were supplied with individual towels in 3 of 3 bathrooms. All client’s bedrooms have lighting & appropriate furnishings, and client’s beds were outfitted with mattress pads as required by Title 22 Regulations # 85088(c)(4). Continue on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 08/29/2023 05:04 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/29/2023 at 03:48 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BEACONLIGHT CARE HOME
FACILITY NUMBER: 216800912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation unlocked cabinet in laundry room with cleaning solutions and unlocked kitchen cabinet with cleaning supplies and cleaning supplies in 2 unlocked bathroom cabinets (see pics). Dangerous items were stored accessible to develop disabled clients in the kitchen at the facility on 8/29/2023 at 1:15 pm (see pics) and unlocked kitchen cabinet with knives & knives on counter (see pics] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Administrator was asked to lock the items during the visit. Administrator will train all staff on regulation 80087(g) and submit a copy with date, time, duration, subject, attendees and their signatures to Community Care Licensing (CCL) to clear the citation by POC due date 08/30/2023.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation Hot water temperature measured between 118.9 degrees F & 125.6 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F , the licensee did not comply with the section cited above in 2 out of 3 clients barhtoom faucets reading 120.9 & 125.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Facility to ensure hot water temperature is maintainted within regulation - 105 to 120 F. Facility to submit a LIC 9098 self certification that hot water has been adjusted to be within regulation by POC date 8/30/2023 & begin monitoring for the next 7 days. Administrator to submit a 7 day log taken from the residnet's bathrooms to CCL by 9/8/2023. ***Faility adjusted hot water during the visit.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2023 05:04 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/29/2023 at 03:48 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BEACONLIGHT CARE HOME
FACILITY NUMBER: 216800912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 facility which poses/posed a potential health, safety or personal rights risk to persons in care. During facility tour on 8/29/2023 with Administrator Wally Hyppolite facility, LPA observed bathroom ceiling with water damage & floor in office & walls and floor in entry way to have dirt and dabret covering (see pics) . In addition, LPA observed trash on the ground in the backyard. See pictures.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee understands facility must be kept in clean, safe, sanitary and good repair at all times for the safety and well-being of clients, employees and visitors. LIcensee agrees to fix/clean backyard, bathroom, & pick up clients bedrooms #3 & #4. Facility must submit pictures via email to LPA of the following corrected items: backyard cleaned, cleaned rooms, and LIC9098 self certification that bathroom ceiling is fixed and that the facility is being maintained/cleaned approperately by POC date of 9/15/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEACONLIGHT CARE HOME
FACILITY NUMBER: 216800912
VISIT DATE: 08/29/2023
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A review of six clients & three staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 1:30 PM on 8/29/2023 and learned that 6 of 6 clients have an updated physician’s report, TB, and signed personal rights on file at this time as required by Title 22 Regulation. However, facility has 5 out of 6 reappraisal/needs & care plan updated for clients due to client C1 just being transferred from sister facility. (see LIC 9102 – Advisory Notes) P&I's are not comingling; facility responsible for five client’s P&I; other client POA and self are responsible for P&I.

Medications were centrally stored in a locked cabinet in the facility office. LPA conducted a review of medications for two clients. The Medications of 2 out of 2 clients were found to be given according to physicians’ directions on 8/29/2023 at 3:15 PM. In addition, LPA reviewed Centrally Stored Medication Records (CSMR) on 8/29/2023 at 3:30 PM and learned that they are currently for 2 out of 2 clients in the facility.

LPA reviewed a sample of staff records at 2:30 PM on 8/29/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received training which is on file for review. LPA was presented with proof of 1st Aid certification for all staff files that were reviewed at this visit. Wally Hyppolite Administrator Certificate # 6002802735 expires on 6/25/2023 and is pending. Disaster Drills have been conducted every 6 months according to facility log file with the last one being conducted on 7/8/2023.

LPA reviewed Licensing Information System (LIS) with Licensee/Administrator Wally Hyppolite who stated that it is corrected and current at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan.



Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEACONLIGHT CARE HOME
FACILITY NUMBER: 216800912
VISIT DATE: 08/29/2023
NARRATIVE
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LPA is requesting the following documents in order to update facility file to be submitted to CCL by 9/15/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Control of Property/Grant Deed of Trust/Lease of Property
Copy of Administrator Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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