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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700281
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:35:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/28/2021 12:35 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LIGHTHOUSE MANORFACILITY NUMBER:
502700281
ADMINISTRATOR:RABANG, CLAIREFACILITY TYPE:
740
ADDRESS:2413 BECKER CTTELEPHONE:
(209) 345-6301
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY: 6CENSUS: 6DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Claire TIME COMPLETED:
12:22 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual/random visit on this date. LPA met with Claire and explained the purpose of the visit.

LPA with Staff inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 116.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present.
LPA observed centrally stored medications locked inside the medication cabinet.

LPA with the assistance of Administrator reviewed and compared resident medication vs. resident medication logs. LPA, Staff and Administrator reviewed 3 resident and 2 staff files, including criminal record clearances. All staff today are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, No deficiencies were cited during this visit. Exit interview held and a report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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