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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202767
Report Date: 04/04/2024
Date Signed: 04/04/2024 05:30:24 PM

Document Has Been Signed on 04/04/2024 05:30 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/
DIRECTOR:		OGLE, FREDFACILITY TYPE:
735
ADDRESS:215 OMIRA DRTELEPHONE:
(408) 772-1220
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Administrator Fred OgleTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Fred Ogle. During the visit, LPA observed 4 residents and 2 staff.

LPA toured the facility inside and outside with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 128 degrees F in the master bedroom bathroom and 132 degrees F in the hallway bathroom.

While touring the hallway bathroom, LPA observed the hallway bathroom door did not shut completely. ADM stated he just bought the new door knob set and was planing on replace it this weekend. ADM stated he will send video its been replaced.

Fire extinguisher was serviced in May 10, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 18, 2024.

LPA reviewed facility records for 2 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. ADM stated he does not handle cash. ADM stated the residents have debit cards. LPA conducted interviews with 1 staff and 2 residents.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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: 04/04/2024
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LPA requested a copy of the following documents to be sent to CCL by April 11, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Any updates for the facility program (incorporating new laws and/or regulations)
8. Copy of surety bond
9. Lease Agreement

Deficiencies cited during today's visit. This report was reviewed with Administrator Fred Ogle and a copy of the signed report was provided. Appeal Rights were provided.

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End of Report.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2024 05:30 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/04/2024 at 05:06 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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's measured facility hot water temperature at 128 degrees F in the master bedroom bathroom and 132 degrees F in the hallway bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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ADM agrees to submit a Plan of Correction by POC date to ensure that water temperatures in the sinks of all resident bathrooms are between 105 F to 120 F. ADM shall submit video evidence to CCL once bathroom sink temperatures are corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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