502700281-1-18-2024-27-AS-JLUD-CZLSZQ-20240118131930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700281
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:19:37 PM

Document Has Been Signed on 01/18/2024 01:19 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	LIGHTHOUSE MANOR		FACILITY NUMBER:	502700281
ADMINISTRATOR:	RABANG, CLAIRE		FACILITY TYPE:	740
ADDRESS:	2413 BECKER CT		TELEPHONE:	(209) 345-6301
CITY:	MODESTO	STATE: CA	ZIP CODE:	95358
CAPACITY:	6	CENSUS: 6	DATE:	01/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:			TIME COMPLETED:	01:45 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 Jason Lund arrived unannounced to conduct an annual/required visit. LPA was met by facility staff and later with Administrator Claire Rabang and explained the reason for the visit. Census: 6 LPA Lund & Administrator Claire Rabang toured the facility and grounds including but limited to: kitchen, dining area, office, common room, bathrooms, resident and staff bedrooms, garage, and yard. There were no bodies of water on the premises. Tour of the facility kitchen area was conducted. LPA observed that there was adequate furniture and lighting for the residents. There were 7-days of non-perishables and 2- days of perishables on hand. Knives were locked in a drawer adjacent to the sink. Toxic items were locked in a separate cabinet above the counter. There were separate refrigerators for staff and residents. The fire extinguisher was located in the kitchen/dining area and observed to have been recently inspected on 01/18/2024 by the local fire extinguisher company, Jorgensen and Company, and in compliance at this time. This facility had an office located off the dining area. Medications were locked and secured in a cabinet. Refrigerated medications were also locked in a small refrigerator in the office. The Medication Administration Record and dispensing log were reviewed and observed to be in compliance at this time. The water temperature in one of resident bathrooms was tested and observed to be within safety guidelines of 105-120 degrees. The water temperature was measured at 112.4 degrees. Grab bars and handrails were observed to be present and functional along with non-skid surfaces in the restrooms and shower area.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIGHTHOUSE MANOR	FACILITY NUMBER: 502700281
	VISIT DATE: 01/18/2024

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Bedrooms were inspected and observed to be in good repair at this time. Resident bedrooms were observed to contain adequate furniture, including nightstands and night lights, in order to meet the needs of the residents at this time. Shared rooms also included a divider for privacy.

LPA toured the exterior grounds and observed the facility to be free and clear of obstacles. There was a locked storage shed and fruit trees present.
The garage was also inspected and had locked cabinets for cleaning supplies and other toxic items. LPA reviewed 3 resident and 2 staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.
There were no deficiencies observed or cited during today's annual visit.
Exit Interview

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

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