435202767-11-16-2023-26-AS-KHOS-CZHR2Z-20240115113910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202767
Report Date: 11/16/2023
Date Signed: 11/16/2023 08:55:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/06/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220106131530

FACILITY NAME:	LIGHTHOUSE VILLA RCF		FACILITY NUMBER:	435202767
ADMINISTRATOR:	OGLE, FRED		FACILITY TYPE:	735
ADDRESS:	215 OMIRA DR		TELEPHONE:	(408) 772-1220
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 4	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Fred Ogle		TIME COMPLETED:	10:18 AM

ALLEGATION(S):

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Staff smokes marijuana inside the facility.
Staff are not following COVID-19 prevention protocols.
Staff are not properly serving resident's meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the complaint investigation findings and met with Administrator (ADM) Fred Ogle.

On 01/06/2022, the Department received a complaint with the above 3 allegations.

On 01/13/2022, the Department conducted an initial investigation visit. The Department interviewed ADM and obtained resident roster, staff roster and food menu.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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 3

Control Number 26-AS-20220106131530

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIGHTHOUSE VILLA RCF	FACILITY NUMBER: 435202767
	VISIT DATE: 11/16/2023

NARRATIVE

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Staff smokes marijuana inside the facility:

On 01/07/2023, an inspection was conducted on the facility including the garage. Based on the observation and inspection, there was no smell of marijuana in the facility and garage. On the same day, all residents were interviewed, none of the residents stated that staff smoked marijuana inside the facility.

On 01/13/2022, the Department interviewed Administrator (ADM). ADM stated he/she used edible marijuana but denied smoking marijuana in the facility.

On 01/14/2022, the Department interviewed a Service Coordinator (SC). SC stated Administrator (ADM) was clean, alert and oriented when SC visited the facility and garage, and spoke with ADM. SC stated ADM admitted smoking but denied smoking marijuana in the facility.

Staff are not following COVID-19 prevention protocols:

On 1/7/2022, CCL office received an incident report from ADM that the facility had a resident (R1) tested COVID positive. R1 was fully vaccinated and with booster shot. Based on the inspection report dated 01/07/2022, during the tour of inspection, R1 was observed isolating at his/her bedroom. R1 put his/her mask on when inspector opened his/her door to check on R1.

On 1/13/2022, the Department interviewed ADM. ADM stated R1 was isolated in his/her room. Staff were wearing full PPEs when entered R1's room to provide care and service to R1. Staff were wearing masks in the facility. Hand sanitizer and disinfectant were available at the facility. ADM stated the facility screened people who came in the facility and logged it. ADM stated the facility reported COVID positive case to CCL office and local health department.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220106131530

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIGHTHOUSE VILLA RCF	FACILITY NUMBER: 435202767
	VISIT DATE: 11/16/2023

NARRATIVE

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Staff are not properly serving resident's meals:

On 01/07/2022, a tour of inspection was conducted. During the inspection, the facility and the facility food supplies were inspected. The food supplies were observed ample and with varieties (fresh fruits, vegetables, canned goods, condiments, meats, cheeses, etc.). 4 residents were interviewed. 4 out of 4 residents confirmed they have meals of their choice. A weekly menu was posted in the kitchen.

On 1/13/2022, The department interviewed ADM. ADM stated the facility provides plenty of food to residents. ADM stated the facility provides good and full cooked dinners to residents.

Based on the observation and the review of facility weekly menu, facility meals served consist of fruits, vegetables, carbohydrates, proteins, and dairy. The facility 2 day perishable food supplies and 7 day nonperishable food supplies were sufficient. The facility provided foods with varieties for residents.

The department has investigated the above allegations. Based on the observations, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC9099 (FAS) - (06/04)

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