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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202767
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:56:59 AM

Document Has Been Signed on 07/23/2024 11:56 AM - 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:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Fred OgleTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management- Deficiencies visit, for deficiencies cited on April 4, 2024. LPA met with Administrator (ADM) Fred Ogle. LPA explained the purpose of the visit, . During the visit, LPA observed 0 residents and 2 staff. Residents were attending day program during LPA's visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 2 residents bedrooms. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA toured the facility garage. LPA observed the garage being used as a storage area. LPA observed the backyard storage shed, being used as a storage area.

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. LPA measured hot water temperature at 117 degrees F in the master bedroom bathroom and 118 degrees F in the hallway bathroom

No deficiencies cited during today's visit. This report was reviewed with staff S1, Romulo Granada and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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