496803621-7-27-2021-21-AS-KLOZ-C5BPRR-20210727113309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803621
Report Date: 07/27/2021
Date Signed: 07/27/2021 11:33:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	LIGHT HOUSE		FACILITY NUMBER:	496803621
ADMINISTRATOR:	PATEL, DHARMISTHA		FACILITY TYPE:	740
ADDRESS:	101 ANISH WAY		TELEPHONE:	(707) 620-0529
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	6	CENSUS: 6	DATE:	07/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Danielle Gates, Caregiver		TIME COMPLETED:	11:45 AM

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) Lopez and Licensing Program Manager (LPM) Mota conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Caregiver, Danielle Gates. LPA conducted a Risk Assessment call with staff prior to the visit. There were 6 residents in care present at the facility. LPA and LPM arrived at the facility and had their temperature checked and signed in on a sheet. LPA continued tour of the facility on July 27, 2021 with caregiver, Danielle Gates. Facility was found to be clean and at a comfortable temperature. LPA Lopez noticed that one of the doors was blocked off with a small table. LPA advised caregiver to clear the door from obstruction and caregiver immediately cleared the table away from the door. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. LPA observed a locked medication box inside fridge. Fire Extinguisher was found to be charged but noticed that the inspector forgot to punch the date on the Fire Extinguisher. Facility will contact provider for correction. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods as required. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LIGHT HOUSE	FACILITY NUMBER: 496803621
	VISIT DATE: 07/27/2021

NARRATIVE

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Facility has submitted a mitigation program plan that has been approved on 1/21/2021. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored 2x/day and results are documented. Facility has a suffiicent supply of PPE and excess supplies stored in the garage. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has agreed to provide donning and doffing training to staff and agreed to disinfect high traffic common areas at least once a day.

No deficiencies cited during today's Required 1- Year inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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