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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403784
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:37:37 PM

Document Has Been Signed on 08/04/2023 12:37 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,
, CA
FACILITY NAME:UNIVERSITY LIGHTHOUSEFACILITY NUMBER:
366403784
ADMINISTRATOR:DAVID NEALFACILITY TYPE:
735
ADDRESS:307 EAST "C" STREETTELEPHONE:
(909) 824-3255
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 4CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Vicki EstelleTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility. During the LPA's investigation deficiencies were found and are documented in this report. LPA met with Administrator, Vicki Estelle who was informed of the purpose of the visit.

LPA reviewed the file for Resident #1 (R1) and found the following:

It was also found that R1 had been taking medication #2 (M1) and had an order from hospital to hold the medication 8/20/2020. Upon review of the MARS log it was found that M1 had been initialed as given from 8/20 to 8/31/2020. LPA interview staff who stated typically residents give the facility discharge paper work and make a notation on the MARS log and stated the facility must not have received the order to stop the medication. Therefore, the facility failed to hold M1 from R1.

LPA conducted interviews and records review and found that on 8/13/2020 R1 was admitted to hospital. The diagnosis was found to be that R1 had overdosed on medication #3 (M2) which had contributed to R1's condition (C1) and lead to intoxication. R1 had a history of overdose which was documented in the facility care plan. R1's care plan stated R1 was classified as "independent". LPA interviewed staff who stated that they were unaware of how R1 was over medicated, and stated they may have gotten it else where as R1 had unsupervised outings in the community. M2 is not a controlled substance. Staff stated they were unaware if the resident's care plan was updated after the incident. Therefore, it was found that there was a lacked of care and supervision from the facility which lead to resident intoxication.

The deficiencies were documented on an LIC809-D page where plans of correction were discussed and created with... An exit interview was conducted where this report, LIC809-D pages, as well as appeal rights were reviewed and provided to Administrator, Vicki Estelle.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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 08/04/2023 12:37 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/04/2023 at 10:16 AM
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
,
, CA

FACILITY NAME: UNIVERSITY LIGHTHOUSE
FACILITY NUMBER: 366403784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/05/2023
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription...medications. This requirment was not met as evidenced by:
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The licensee agreed to have in an inserviced with staff on ensuring medical orders are received following a residents hospital visit to ensure doctors orders are followed.
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Through records review and interview it was found that facility did not hold M1 from R1 despite doctor's orders. This poses an immediate health, saftey or personal rights risk.
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Inservice documents are due to LPA by POC due date.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2023 12:37 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/04/2023 at 10:21 AM
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
,
, CA

FACILITY NAME: UNIVERSITY LIGHTHOUSE
FACILITY NUMBER: 366403784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/05/2023
Section Cited
CCR
80078(a)

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(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirment was not met as evidenced by:
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Licensee agreed to hold an inservice with staff on the enhancedd supervision for residents who need it, such as those with history of substance abuse. Proof of
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It was found through interviews and records that R1 overdosed on M1. Facility lacked preventative measures such as supervision. This poses an immideiate health saftey or personal rights risk.
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the material used for the inservice shall be sent to the LPA by the POC due date.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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