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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202767
Report Date: 06/27/2023
Date Signed: 06/27/2023 05:14:41 PM

Document Has Been Signed on 06/27/2023 05:14 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:
06/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Fred OgleTIME COMPLETED:
05:15 PM
NARRATIVE
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On 06/27/2023, LPA Monter and LPM Manzano conducted a case management visit– deficiencies visit. LPAs 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 not submitted or corrected citations 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.
• Health and safety code 1565(c), Issued initial CP of $100.00 beginning 6/17 and will continue to accrue until corrected.
• 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.
• Title 22, Code Section 80066(a)(11), Personnel Records/Type B. CP will be assessed from 6/17 until corrected.

The following deficiency issued because of a complaint investigation on 06/13/2023 as follows:
• Title 22, Code section 80072 (a)(2) Personal Rights, Type A Issued CP $1000.00 from 6/17 to 6/26/2023 and will continue to accrue. CLEARED DURING VISIT.

CP issued today for the maximum of $300. LPA informed licensee that if the 4 deficiencies are not corrected, civil penalty will continue to accrue until corrected.

LPA discussed about the importance of Plan of Correction. License agreed and understood.

Page 1 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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
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: 06/27/2023
NARRATIVE
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During today's visit, LPA observed unsecured cleaning detergents( such as clorox, fabuloso, scrubbing bubbles), a can of paint, and gardening tools in the facility's sun room and garage(laundry area). LPA noted boxes in the sun room that need to be addressed. The facility common bathtub is currently being replaced wherein ADM's restroom is temporarily being used by residents. ADM stated that it will take another a week or two. ADM advise to submit a plan of action on usage of ADM's bathroom such as personal rights.

A review of ADM's file, ADM did not have a current first aid training was not found and staff (S1). ADM also did not have his administrators license has not been renewed.

During today's inspection deficiencies were issued. See LIC809D. Appeal rights were provided.
This report was reviewed with Licensee Fred Ogle. A copy of this report was provided during exit interview.

Page 2 out of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/27/2023 05:14 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/27/2023 at 03:42 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: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2023
Section Cited
CCR
80065(f)(1-7)

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80065 Personel requriements (f)(1-7) All personnel shall be given on-the-job training or shall have related experience which provides knowledge ... as evidenced by safe and effective job performance
This requirement was not met as evidenced by:
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ADM stated he will provide for S1 training for the next two weeks on 7/11/2023.
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Based on interview with ADM, ADM stated that S1 began working on 1/2023 as a direct care staff who works Part time. S1 does not have training. This poses an immediate health, safety or personal rights risk to persons in care.
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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: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/27/2023 05:14 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/27/2023 at 03:53 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: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2023
Section Cited
CCR
80064(a)(3,7)

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80064 Administrator Qualifications & duties (a)(3,4,7) the administrator shall have the following... Knowledge of and ability to comply with applicable... regulation...ability to maintain...other records...Ability to ... train, and evaluate qualified staff. This requirement was not met as evidenced by
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ADM stated he will submit a statement on not to procastinate and fuflil his duty's as ADM. And engage and communicate with CCL and other agencys. To proactive on regulations. ADM will send written statment with signiture by POC date.
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Based on 5/10/23 & 6/27/23 inspection and investigations, the facility failed to correct POCs. Resident and personel files are incomplete. ADM unawre of current CCL updates such as Gaurdian and PINS. This poses an immediate health, safety or personal rights risk to persons in care.
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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: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/27/2023 05:14 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/27/2023 at 04:45 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: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2023
Section Cited
CCR
80087(g)

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80087 Building and Grounds(g)Disinfectants, cleaning solutions, poisons... and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by;
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ADM stated he will move toxics, cleaning detergents and gardening tools to a secure location that is not accessible to residents in care by POC.
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Based on inspection, LPA observed toxic materials, gardening tools, and cleaning detergents were observed accessible to clients in care. which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/28/2023
Section Cited
CCR80075(f)

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80075 health related services(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
This requirement was not met as evidenced by;
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ADM stated he will complete the first aid training registration and will send proof of registration for first aid training by POC date.
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Basd on inteview and review of faciltiy staff files; ADM stated he has not completed first aid training. This poses an immediate health, safety or personal rights risk to persons in care.
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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: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023


LIC809 (FAS) - (06/04)
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