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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700281
Report Date: 02/13/2023
Date Signed: 02/14/2023 09:50:20 AM

Document Has Been Signed on 02/14/2023 09:50 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
SACRAMENTO AC/SC, 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: 5DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Claire RabangTIME COMPLETED:
12:30 PM
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Unannounced annual visit conducted on 02/13/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella to this facility and were met by facility staff, Rumel Valdez, who was briefly interviewed. LPAs requested that the facility staff person Rumel Valdez contact the facility designated administrator, Claire Rabang, to inform her that CCL was present at this time. The facility designated Administrator Claire Rabang arrived shortly thereafter. The current census for the facility was 5 residents. All 5 residents were out of the facility at this time attending their respectable Day Programs. The staff roster was reviewed.
LPAs 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. LPAs observed that there was adequate furniture and lighting for the residents. There were 7 days worth of non-perishables and 2 days worth 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 resident refrigerator was inspected and contained an adequate supply of 2 days perishable food items. There was also a pantry that contained a sufficient supply of 7 days non-perishables food items at this time.

The fire extinguisher was located in the kitchen/dining area and observed to have been recently inspected on 01/4/2023 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 111.7 degrees. Grab bars and handrails were
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LIGHTHOUSE MANOR
FACILITY NUMBER: 502700281
VISIT DATE: 02/13/2023
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observed to be present and functional along with non-skid surfaces in the restrooms and shower area.
Bedrooms were inspected and observed to be in good repair at this time. Resident bedrooms were observed to contain adequate furniture, including night stands and night lights, in order to meet the needs of the residents at this time.. Shared rooms also included a divider for privacy.

LPAs 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. There were also tables and chairs along with exercise equipment for the residents to use in warmer weather. The area was observed to be organized and in good repair at this time.

The administrator's certificate for Claire Rabang, was current and up to date. The expiration date for this certificate was for 08/26/2024 and in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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