<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426757
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:24:45 PM


Document Has Been Signed on 09/16/2022 03:24 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LIGHTSHINE HOME CAREFACILITY NUMBER:
366426757
ADMINISTRATOR:ABIGAIL NAVARROFACILITY TYPE:
740
ADDRESS:1400 PURDUE STREETTELEPHONE:
(909) 931-1568
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 6DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Abigail NavarroTIME COMPLETED:
02:33 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Natalie Ibarra made an unannounced visit to the facility. The purpose of today's visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with Administrator Abigail Navarro.

LPA Ibarra toured the facility and went over COVID-19 best practices for infection control and prevention with the Administrator. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a temperature check and a symptom check. The staff working at the facility were all face mask. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Ibarra requested to inspeoct the facility's Personal Protective Equipment (PPE) supply. The facility has a full thirty (30) day supply of PPE such as gloves, face shields, surgical masks, N95 masks, disinfectant, and hand sanitizer. During tour LPA observed the second back gate door to the pool area be unlock and broken. A deficiencies will be issued on the attached LIC 809D.

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were discussed and provided to the Administrator.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie IbarraTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/16/2022 03:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: LIGHTSHINE HOME CARE
FACILITY NUMBER: 366426757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Second gate to pool area was broken which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2022
Plan of Correction
1
2
3
4
Licensee will repair/replace broken gate. Licensee will send picture to LPA showing gate has been replaced/repair by POC date 9/17/22
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above. Second gate to pool area did not have a lock on the gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2022
Plan of Correction
1
2
3
4
Licensee will purchase a new lock and place on pool area gate. Licensee will send LPA a picture of locked gate by POC date 9/17/22

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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie IbarraTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2