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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803621
Report Date: 06/21/2024
Date Signed: 06/21/2024 11:28:16 AM


Document Has Been Signed on 06/21/2024 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:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Dharmi Patel (Licensee)TIME COMPLETED:
11:43 AM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Dharmistha Patel. There is currently 2 residents in hospice. Required postings were observed. Fees are current. Contact information was reviewed.

LPA/Licensee initiated tour of facility at 9:00 am. Hot water measured 107.1, 112.1 and 109.6 degrees F which is within range of 105-120 degrees F. Carbon monoxide detector and smoke detectors were checked and were operational. Fire extinguishers were charged and inspected on March, 2024. Last Disaster Drill was conducted on April 1, 2024 Facility temperature was 73 degrees F. Passageways were free from obstructions. Residents rooms were furnished per regulation. Grab bars observed in toilet/shower areas. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods. Refrigerator clean and food stored properly. Medications centrally stored in kitchen drawers. Knives are located in a locked closet in the kitchen. Auditory alarms on exit doors. During the walk through LPA had a discussion with Licensee due to bedrooms were labeled differently as stated in their fire clearance Room# 1 is labeled as #2, room #2 is labeled as #3, room #3 is labeled as #4 and room #4 is labeled as #1, which are not the same locations indicated on their fire clearance approved on 5/27/2016. Based on LPA's records review it was determined that no residents currently have a bedridden status. Licensee agreed to submit pertinent documentation to the Department to have the Fire Inspector to revise current fire clearance and rooms, because they need to clarify which rooms could eventually be used for bedridden residents if needed. Fire clearance approved 5/27/16 indicates that room#3, 4 and 6 could be used for bedridden residents. Medication and medication records were reviewed.

Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LIGHT HOUSE
FACILITY NUMBER: 496803621
VISIT DATE: 06/21/2024
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Continued from LIC809...

File Review was initiated at 10:00am. Five resident and three staff files were reviewed. All residents have current medical assessments and apraisal/needs and services plans. Staff have required First Aid and CPR certificates and training hours completed. Administrator Dharmistha Patel 6033357740 expires 1/8/2025.

Licensee to submit updates of the following documents by 7/1/2024:

- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (LIC610E if there are any changes)
- Control of property (Lease agreement).
- Liability insurance was already submitted to the Department prior to this visit.

No deficiencies were cited during today's inspection. Exit interview was conducted with Licensee and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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