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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202767
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:40:03 PM

Document Has Been Signed on 08/15/2023 03:40 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:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Fred OgleTIME COMPLETED:
03:45 PM
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On 06/27/2023, LPA Monter and LPM Manzano conducted a case management visit– deficiencies visit. LPA met with Administrator, Fred Ogle

On 5/10/2023, the facility was issued the following citations with a POC date 05/17/2023. On 05/17/2023, the licensee requested POC extension from 05/17/2023 to 06/17/2023. As of today’s visit, the licensee has corrected citations past POC date, resulting in civil penalties.
The following deficiencies during an annual inspection on 05/10/2023 are as follows:
• 80066(a)(12)(B)1, Personnel Records (Type B), Issued initial Civil Penalty (CP) of $100.00 beginning 6/17 and will continue to accrue until corrected. CLEARED ON 08/01/2023
• Health and safety code 1565(c), Issued initial CP of $100.00 beginning 6/17 and will continue to accrue until corrected. CLEARED 07/03/2023
• Title 22, Code Section 85070(a)(3), Client records/ Type B. Issued initial CP of $100.00 beginning 6/17 and will continue to accrue until corrected. CLEARED ON 08/01/2023
• Title 22, Code Section 80066(a)(11), Personnel Records/Type B. CP will be assessed from 6/17 until corrected. CLEARED ON 08/01/2023

Civil Penalties were issued today.

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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
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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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
VISIT DATE: 08/15/2023
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The following are deficiencies that were created during a Case management visit on 06/27/2023 are as follows:
80065(f)(1-7) Personnel requirements, Type B, POC date 07/11/2023. POC CLEARED on 07/11/2023

80064(a)(3,7) Administrator Qualifications & Duties, Type A, POC date 06/28/2023. POC CLEARED ON 06/28/2023.

80087(g) Building and Grounds, Type A. POC date 06/28/2023. POC CLEARED ON 06/28/2023

80075(f) Health Related Services (f) Type A, POC date 06/28/2023. POC CLEARED ON 06/28/2023.

This report was reviewed with Licensee Fred Ogle. A copy of this report was provided during exit interview.

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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
LIC809 (FAS) - (06/04)
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