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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803621
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:28:15 AM


Document Has Been Signed on 07/07/2023 11:28 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:LIGHT HOUSEFACILITY NUMBER:
496803621
ADMINISTRATOR:PATEL, DHARMISTHAFACILITY TYPE:
740
ADDRESS:101 ANISH WAYTELEPHONE:
(707) 620-0529
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 5DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Dharmi Patel (Licensee)TIME COMPLETED:
11:43 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Dharmi Patel. There are residents with diagnosis of Dementia and Hospice Services.

LPA/Licensee initiated a tour of the facility around 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Hot water temperature in bathrooms used by residents measured at 114.6, 114.8 and 115.2 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Two fire extinguisher was last serviced March 2023. One carbon monoxide detector in the hallway was tested and properly working. Last disaster drill conducted on 5/3/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Dharmi Patel, 6033357740, expired on 1/8/2025. Medications were reviewed, centrally stored and locked.

LPA initiated file review at 10:00 am. LPA reviewed five residents files and five staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training.

Licensee agreed to submit updates of the following documents by 7/21/23: Administrative Organization (LIC309), Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Copy of property taxes, Copy of Liability Insurance, LIC 610 Emergency Disaster Plan (If changes) and Infection Control Plan (If changes).
No deficiencies cited during today's inspection.

Exit interview was conducted with Licensee and a copy of this report was provided.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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