435202767-4-19-2026-26-AS-MPAA-DTB6T6-20260419210501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202767
Report Date: 04/17/2026
Date Signed: 04/19/2026 09:09:17 PM

Document Has Been Signed on 04/19/2026 09:09 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 RCF		FACILITY NUMBER:	435202767
ADMINISTRATOR/ DIRECTOR:	OGLE, FRED		FACILITY TYPE:	735
ADDRESS:	215 OMIRA DR		TELEPHONE:	(408) 772-1220
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 4	DATE:	04/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:04 AM
MET WITH:	Fred Ogle		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required one year inspection and met with Licensee/Administrator (LIC/ADM) Fred Ogle. LPA explained the purpose of the visit. The facility is licensed to serve six (6) ambulatory adults ages 18–59. During the visit, LPA observed one (1) of four (4) residents present in his room resting. LPA conducted a tour of the facility, including common areas, resident rooms, kitchen, bathrooms, garage, driveway, outdoor areas, and storage spaces. Upon entry, LPA observed an odor consistent with cigarette smoke. The entryway was unobstructed. The living area was clean and organized, and no tripping hazards were observed. Resident rooms contained adequate storage for personal belongings. The kitchen was sanitary and organized. Knives were observed unsecured. Cleaning chemicals under the sink were locked. Food supply met the required quantities of at least two (2) days of perishable and seven (7) days of non-perishable food. An additional refrigerator and a stand-up freezer were located in the kitchen and in the food pantry/supply area in the sun room adjacent to the kitchen. Medications were locked and inaccessible to residents. The first aid kit was complete. see page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

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

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 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: 04/17/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In the bathrooms, LPA observed grab bars and non-skid mats. Cleaning chemicals, including Comet Bleach, Lysol disinfectant spray, and Scrubbing Bubbles Grime Fighter, were observed unsecured under the bathroom sink.

The sliding door to the backyard was unobstructed; however, the screen on the door handle was frayed. LPA observed a 2.37 gallon container of Pinalen multipurpose cleaner and gardening soil in the backyard.

Walkways to the side gate were clear. Indoor temperature measured 64.4°F. Kitchen water temperature measured between 126.6°F and 126.8°F. Bathroom water temperatures ranged from 127.4°F to 131.4°F. Refrigerator temperature measured 39°F and freezer temperature measured 0°F.

The laundry area, located in the garage, was operational. Fire, smoke, and carbon monoxide systems were tested by the administrator during the visit and verified to be operational. Hallways were clear, well-lit, and free from tripping hazards. The facility is equipped with a fire extinguisher but has no information as to when it was last inspected.

LPA reviewed 2 resident and 2 staff files, including medication logs, admission agreements, care plans, personal and incidental (P&I) records, health screenings, and training documents. All staff had required background and fingerprint clearances. 2 out of 2 staff record review did not have the 1st Aid/CPR certification on file. ADM stated staff went to training and certificates will be provided at later time due to misplacement a technical violation was issued for CCR 80075(f)

LPA reviewed the facility record. The facility conducts quarterly fire and earthquake drills for each shift. The most recent fire and earthquake drill was conducted on 09/04/25 and 09/06/25. The facility's mass casualty information posted on the wall was dated 01/10/2008. ADM stated that he/she will provide an updated to LPA, a technical violation was issued for 80023(a). No mass casualty were conducted by the facility.

Deficiencies were cited during today's visit based on Title 22 of the California Code of Regulations (CCR), refer to LIC 809D for information of the deficiencies cited. An exit interview was conducted with licensee/ administrator Fred Ogle and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 04/19/2026 09:09 PM - It Cannot Be Edited

Created By: Maria Partoza On 04/17/2026 at 10:18 AM

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: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(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
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not ensuring that hot water delivered to plumbing used by clients does not exceed 120 degrees F. The hot water temperature when measured by a digital thermomenter in bathroom was at 127.4°F to 131.4°F and the kitchen hot water measured 126.6°F and 126.8°F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2026
	Plan of Correction
1 2 3 4	LIC/ADM stated that he/she will submit a written plan of correction to address the water temperature and ensure that hot water is maintained between 105 degree F and not more than 120 degree F. ADM will submit the written plan of correction by the POC due date of 04/18/2025.

Type A

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not conducting fire and earthquake drill from 09/04/25 and 09/06/25, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2026
	Plan of Correction
1 2 3 4	LIC/ADM stated that he/she will submit a written plan of correction to ensure that earthquake and fire drill are consistently done every quarter and will submit the plan of correction by the due date of 04/18/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/19/2026 09:09 PM - It Cannot Be Edited

Created By: Maria Partoza On 04/17/2026 at 11:28 AM

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: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in by not ensuring disinfectants, cleaning solutions, are not readily accessible to cliensts such as, LPA observed, knives, Comet bleach, Lysol Disinfectant, Scrubbing Bubbles, a 2.37 Gallon of PinaLen multipurpose cleane under the bathroom sink and kitchen drawer, that were easily accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2026
	Plan of Correction
1 2 3 4	LIC/ADM stated that he/she will submit a written plan of correction to ensure that knives, disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients are stored in where it is not easily accessible to residents in care. LIC/ADM stated that he/she will submit the plan of correction by the POC due date of 04/18/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC809 (FAS) - (06/04)

Page: 5 of 5