496803621-6-13-2025-21-AS-MCUA-DHLQPS-20250613122113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803621
Report Date: 06/13/2025
Date Signed: 06/13/2025 12:21:22 PM

Document Has Been Signed on 06/13/2025 12:21 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	LIGHT HOUSE		FACILITY NUMBER:	496803621
ADMINISTRATOR/ DIRECTOR:	PATEL, DHARMISTHA		FACILITY TYPE:	740
ADDRESS:	101 ANISH WAY		TELEPHONE:	(707) 620-0529
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY: 6		CENSUS: 5	DATE:	06/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Dharmi Patel (Licensee)		TIME VISIT/ INSPECTION COMPLETED:	12:35 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) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Dharmistha Patel. There are residents receiving hospice services. Required postings were observed. Fees are current. Contact information was reviewed. LPA/Licensee toured the facility, passageways were free from obstructions, temperature measured 70 degrees F, residents' rooms appeared furnished per regulation. Hot water measured 108.5, 114.8 and 106.3 degrees F which is within range of 105-120 degrees F. Grab bars observed in toilet/shower areas. Extra hygiene products and linens were available. Carbon monoxide detector and smoke detectors were checked and were operational. Fire extinguishers were charged and inspected on March, 2025. Last Disaster Drill was conducted on April 4, 2025. Facility has at least two days of perishable and one week of non-perishable foods. Medications centrally stored in kitchen drawers. Items that could pose a risk to residents along with disinfectants, cleaning solutions are maintained locked in a closet located in the kitchen. Auditory alarms on exit doors were operational. File Review was initiated at 10:00am. Five resident and three staff files were reviewed. All residents have current medical assessments and appraisal/needs and services plans. Staff have required First Aid and CPR certificates and training hours completed. Administrator Dharmistha Patel 7009824740 expires 1/8/2027. Medication and medication records were reviewed. Continues on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

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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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)

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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: 06/13/2025

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Continued from LIC809...

During last annual LPA had a discussion with Licensee due to bedrooms were labeled differently as stated in their fire clearance, 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 the Licensee submitted some documentation, but process was not completed timely to correct labeling discrepancy. Today, 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.

LPA/Licensee discussed Dementia regulation changes and provided resources including LIC602A form for their review.

Licensee agreed to submit updates of the following documents by 6/27/2025:

- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500) was already submitted to the Department prior to this visit.
- 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.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

LIC809 (FAS) - (06/04)

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