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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202767
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:47:06 PM

Document Has Been Signed on 05/10/2023 04:47 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee Fred OgleTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA)Manuel Monter and Licensing Program Analyst Steve Chang conducted an unannounced Required 1 Year visit and met with Licensee Fred Ogle.

LPAs toured the facility inside and out. LPAs toured the facility in the following area: resident/staff bedrooms, kitchen, hallway free from obstructions, living and dining area. Food supplies were also inspected for both 7 days non-perishable and 2 days perishables. Facility first aid kit was observed and met the requirement. Toxic materials and sharp or hazardous objects were observed inaccessible to residents in care. The facility had toiletries. There are two bathrooms/shower with grab bars and skid mats. The facility hot water temperatures in the following areas are measured with thermometer. The temperature varies from 106.1-109 degrees F.

Facility smoke detectors including carbon monoxides were observed and tested and found to be functioning. The facility yard was inspected and no tripping hazards or hazardous items observed during inspection.The facility fire extinguisher was also inspected and did not have a tag indicating when it was last inspected. Licensee bought fire extinguisher during visit.

During inspection of the facility, LPA's observed a storage unit in the backyard; its was only being used as storage.
LPA's did not observe facility records for staff and residents due to Licensee stating they could not find the documents. LPA reviewed resident medications and centrally stored medication records for 4 residents. LPA conducted interviews with 1 staff (S1) and 4 residents. Licensee stated that the facility does not handle cash resources.
During today's inspection Technical Violation (TV) and deficiencies were issued. See LIC9102 and lic809d.

This report was reviewed with Licensee Fred Ogl. A copy of this report was provided during exit interview.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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 5
Document Has Been Signed on 05/10/2023 04:47 PM - It Cannot Be Edited


Created By: Manuel Monter On 05/10/2023 at 03:58 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
, 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: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above based on four out of four staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Licensee stated they will send over updated staff files to LPA by POC date.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in four out of four staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Licensee stated they will update personal records and send copy to LPA by POC date.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document is an Amendment of Original Document on 06/27/2023 10:10 AM


Created By: Manuel Monter On 05/10/2023 at 03:58 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
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: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview and record review, the licensee did not comply with the section cited above in 4 out of 4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Administrator stated they will submit documentation that a fire drill has taken place and updated policy regarding fire drills and smoke detector maitennce.
Type B
Section Cited
CCR
85070(a)(3)
885070(a)(3) In addition to Section 80070, each client record must contain the following information: (3)Needs and Services Plan

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in four out of four resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Licensee stated they will submit update needs and services plan for all four resident by poc date.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5