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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202767
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:43:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20200820090025
FACILITY NAME:LIGHTHOUSE VILLA RCFFACILITY NUMBER:
435202767
ADMINISTRATOR:OGLE, FREDFACILITY TYPE:
735
ADDRESS:215 OMIRA DRTELEPHONE:
(408) 772-1220
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Administrator Fred OgleTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility failed to report an incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Fred Ogle.

On 8/20/2020, the department received a complaint that the ADM failed to report an incident. It has been alleged that on 6/3/2020 resident R5 passed out due to dehydration. The paramedics came but did not take him/her to the hospital. It has also been alleged that this was not reported to CCL.

On 08/27/2020 LPA Donovan interviewed R5. R5 confirmed that he/she did have an incident where he/she became dehydrated and passed out. R5 confirmed that the paramedics did come and check on him/her.

Page 1 out of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 26-AS-20200820090025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LIGHTHOUSE VILLA RCF
FACILITY NUMBER: 435202767
VISIT DATE: 08/15/2023
NARRATIVE
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On 08/26/2020 LPA Donovan interviewed ADM. ADM confirmed that he/she did not report the incident and that he/she just didn’t do it and he/she messed up.

Based on interviews, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Fred Ogle and a copy of the report was provided. Appeal Rights was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20200820090025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIGHTHOUSE VILLA RCF
FACILITY NUMBER: 435202767
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
Section Cited
CCR
80061(b)
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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the event specified...a report shall be made to the licensing agency within the agency's next working day
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ADM stated she will submit a written plan of understanding the regulation and ensuring reports will be made to licensing in a timely manner, by POC date.
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Based on interview with ADM, ADM confirmed that the facility did not make an incident report or call the licensing agency to report the incident. This poses a potential heath, safety and personal rights risk to persons 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20200820090025

FACILITY NAME:LIGHTHOUSE VILLA RCFFACILITY NUMBER:
435202767
ADMINISTRATOR:OGLE, FREDFACILITY TYPE:
735
ADDRESS:215 OMIRA DRTELEPHONE:
(408) 772-1220
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Administrator Fred OgleTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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5
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9
Administrator screams at staff in front of clients

Falsification of document
INVESTIGATION FINDINGS:
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Administrator screams at staff in front of residents.
On 8/20/2020, the Department received a complaint that the ADM screams at staff in front of the residents.

On 08/26/2020 Licensing Program Analyst (LPA) Donovan interviewed ADM. ADM denied the allegation that he/she yells at staff in front of residents.

LPA Donovan interviewed residents R1-R5. R1 & R2 denied the allegation that the ADM was yelling at staff. R4 stated ADM and staff (S1) argue but has not observed any arguing in front of him. R3 stated that he/she has observed ADM & S1 yelling and that S1 yells at everyone. R5 stated he/she has observed ADM and S1 yelling at each other. R5 stated this made him uncomfortable.
Page 1 out of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20200820090025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LIGHTHOUSE VILLA RCF
FACILITY NUMBER: 435202767
VISIT DATE: 08/15/2023
NARRATIVE
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On 08/15/2023 LPA Monter interviewed residents R1, R2, R4, & R5. (R3 has moved). R5 stated S1 would yell at ADM. R5 stated S1 would get mad for no reason. R5 stated S1 would yell at ADM in front of the residents. Resident R1 & R4 stated they do not remember. Resident R2 stated ADM and S1 did not yell.

Based on the interviews conducted with clients, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Falsification of document

On 8/20/2020, the department received a complaint that alleged that the ADM would falsify medication records. It has been alleged the ADM will forget to give residents their medications, ADM would then falsify on the Medication Administration Records (MARs) that the medication was given.

On 8/27/2020 LPA Donovan interviewed S1. S1 stated he/she took over the medication in June 2020.

On 8/27/2020 LPA Donovan interviewed residents R1-R5. All residents interviewed stated that the ADM and S1 have never missed giving out medications.

On 05/10/2023 and 06/13/2023 LPA Monter conducted a complaint investigation regarding staff not administering medications. LPA audited resident medications and facility MARs. Audit included reviewing bubble packs, medication bottles while cross referencing facility MARs to make sure there wasn’t a discrepancy in either the MAR or the medication container itself. LPA found no discrepancies during medication audits on 5/10/2023 and 6/13/2023.

Based on the interviews conducted & 2020 medication containers no longer being available for LPA to audit, LPA cannot prove or nor disprove the above allegations did or did not occur in 2020. Therefore, the allegations are UNSUBSTANTIATED.

This report was reviewed with Licensee Fred Ogle. A copy of this report was provided during exit interview.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7