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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880832
Report Date: 09/08/2021
Date Signed: 09/08/2021 01:24:49 PM

Document Has Been Signed on 09/08/2021 01:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LIGHTHOUSE RESIDENTIAL CAREFACILITY NUMBER:
331880832
ADMINISTRATOR:CANADA, EVA & SCOTTFACILITY TYPE:
740
ADDRESS:21710 PINK GINGER COURTTELEPHONE:
(951) 249-6798
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 6CENSUS: 5DATE:
09/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eva CanadaTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer Semin conducted this case management visit in conjunction with Complaint number 18-AS-20210901160701. LPA met with administrator Eva Canada.

During the course of the complaint investigation on 9/8/2021. At 12:16pm LPA observed the kitchen, with no staff present, and the medicine cabinet next to the kitchen to be unlocked and accessible to residents in care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by staff were not present and medication cabinet was left unlocked with residents present.. This poses an immediate health and safety risk to residents in care. A deficiency will be cited.

An exit interview was conducted where this report was discussed and provided to Ms. Canada.
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SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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 09/08/2021 01:24 PM - It Cannot Be Edited


Created By: Jennifer Semin On 09/08/2021 at 12:48 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LIGHTHOUSE RESIDENTIAL CARE
FACILITY NUMBER: 331880832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2021
Section Cited
CCR
87465(h)(2)

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INCIDENTAL MEDICAL AND DENTAL CARE
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This
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Licensee shall read the regulation in its entirety, train staff on this regulation and submit a statement of understanding and training log to CCL by the POC due date of 9/9/2021.

Licensee locked cabinet.
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requirement was not met as evidence by staff was not present and medication cabinet was left unlocked with residents present.. This poses an immediate health and safety risk to residents in care.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Jennifer Semin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021


LIC809 (FAS) - (06/04)
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