Light House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Dharmi Patel. There are residents with diagnosis of Dementia and Hospice Services. LPA/Licensee initiated a tour of the facility around 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Hot water temperature in bathrooms used by residents measured at 114.6, 114.8 and 115.2 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Two fire extinguisher was last serviced March 2023. One carbon monoxide detector in the hallway was tested and properly working. Last disaster drill conducted on 5/3/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Dharmi Patel, 6033357740, expired on 1/8/2025. Medications were reviewed, centrally stored and locked. LPA initiated file review at 10:00 am. LPA reviewed five residents files and five staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training. Licensee agreed to submit updates of the following documents by 7/21/23: Administrative Organization (LIC309), Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Copy of property taxes, Copy of Liability Insurance, LIC 610 Emergency Disaster Plan (If changes) and Infection Control Plan (If changes). No deficiencies cited during today's inspection. Exit interview was conducted with Licensee and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Dharmi Patel. LPA/Licensee reviewed PIN 22-07, 22-09, 22-13, 22-15 & 22-16. LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility have posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least three times a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 1/21/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are accessible for staff. Licensee agreed to provide updates of the following by 6/9/22: Liability insurance and Emergency Disaster Plan (LIC610E). No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Jun 2, 2022

Allegation investigated: Facility is not allowing visitation

Licensing Program Analyst (LPA) Cuadra conducted an unannounced complaint investigation regarding the above allegation and met with Licensee, Dharmi Patel for the purpose of closing the complaint. It was alleged that facility is not allowing visitation. Reporting party called CCL to report that resident (R1) was not being allowed visitors. LPA conducted 10-day complaint inspection on 2/25/22 and conducted confidential interviews with staff, resident and R1’s fiduciary. Based on records review and confidential interviews, responsible parties and fiduciary who handles R1’s health and financial decisions has requested facility to not allow visitors for R1 due to different matters. However, during records review, there is no legal documentation preventing any visitors to come and visit R1. Facility provided documentation along with visitor’s sign-in sheets for the month of January and February 2022 that indicates that the facility is allowing visitors for residents in care. LPA also conducted interviews with R1 who expressed their wishes to continue to receive visitors and relations with persons of their preferences. Continues on LIC9099C... Substantiated Continued from LIC9099... Based on LPA’s observations, interviews which were conducted and review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8 and the Health and Safety Code), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 21-AS-20220217163350

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Mar 24, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: (11) To have their visitors…permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement has not been met as evidence by: Based on records review and interviews with Licensee and outside parties, facility was not allowing visitors to R1 which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2022

Plan of correction: Licensee will ensure that residents rights are maintained and R1 will be able to receive visitors. Licensee will submit a self-certification (LIC9098) that all staff had been notified about regulation by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lopez and Licensing Program Manager (LPM) Mota conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Caregiver, Danielle Gates. LPA conducted a Risk Assessment call with staff prior to the visit. There were 6 residents in care present at the facility. LPA and LPM arrived at the facility and had their temperature checked and signed in on a sheet. LPA continued tour of the facility on July 27, 2021 with caregiver, Danielle Gates. Facility was found to be clean and at a comfortable temperature. LPA Lopez noticed that one of the doors was blocked off with a small table. LPA advised caregiver to clear the door from obstruction and caregiver immediately cleared the table away from the door. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. LPA observed a locked medication box inside fridge. Fire Extinguisher was found to be charged but noticed that the inspector forgot to punch the date on the Fire Extinguisher. Facility will contact provider for correction. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods as required. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Continued on LIC809-C Facility has submitted a mitigation program plan that has been approved on 1/21/2021. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored 2x/day and results are documented. Facility has a suffiicent supply of PPE and excess supplies stored in the garage. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has agreed to provide donning and doffing training to staff and agreed to disinfect high traffic common areas at least once a day. No deficiencies cited during today's Required 1- Year inspection.the state’s words, verbatim · CDSS document, Jul 27, 2021

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.