The Lighthouse

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:31 AM. LPA met with facility staff who contacted the Administrator Gabriela Visovan. The Administrator arrived to the facility at 10:06 AM. Entrance interview was conducted and the reason for the visit was explained. Beginning at 10:08 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: This included the activity room, hallway, and dining room areas. LPA observed the activity room to be clean and properly furnished at the time of the visit. The common activity room contained a television and activities for resident use. The dining room contained adequate seating for resident use. Cameras were observed in the common areas and hallways throughout the facility. LPA observed the hallway to contain a dry food storage closet, the locked medication room, the Administrator’s office, a common resident bathroom, and a shower room. Additionally the hallway was observed to contain the activity calendar, emergency exit sketches, and other required postings. The LPA observed fire extinguishers throughout the facility to be fully charged and last serviced on 02/18/2026. Smoke detectors and carbon monoxide detectors were last tested on 07/26/2026 and were functional at the time of the test. BEDROOMS: There are twenty-seven (27) bedrooms in the facility; all are designated for resident use. LPA and facility Administrator toured ten (10) resident rooms. All viewed resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. CONTINUED ON LIC 809C. BATHROOMS: Each bedroom in the facility has an attached private resident bathroom. Additionally, there is a shared resident bathroom and a shared shower room located in the hallway of the facility. LPA and Administrator observed ten (10) private resident bathrooms and the shared resident bathroom. Bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed next to all toilets and in all showers and all were properly secured. The water temperature was measured to be between 108.1 and 118.4 degrees Fahrenheit, which is in compliance with regulation. KITCHEN: The LPA observed the kitchen area to be clean and inaccessible to clients in care. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days’ perishable and seven (7) days non-perishable food. The facility had an adequate supply of emergency food and water. OUTDOOR SPACE: LPA observed the outdoor area to have sufficient space for outdoor activities. The patio was observed to contain adequate patio furniture including shaded tables and chairs for residents’ use. The patio of the facility contained a small water fountain. LPA observed a locked laundry room and a locked storage room. The facility had an emergency exit gate, LPA observed clear passageways for emergency exit use. RECORD REVIEW: Record review began at 10:53 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation and signatures. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at approximately 12:20 PM. Medications are stored centrally and securely in the medication room. Medications for five (5) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. CONTINUED ON LIC 809C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The last emergency disaster drill was conducted 06/17/2026. The facility’s emergency disaster plan is up to date and adequate. Both the infection control plan and emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed three (3) staff and three (3) residents. All residents stated that staff treat them well and are attentive to their needs. Residents interviewed did not have concerns with the quality of care they received at the facility. All staff interviewed were knowledgeable on their roles and responsibilities, the residents’ rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s updated emergency disaster plan, current liability insurance, employee roster, and resident roster. No deficiencies were observed during today’s inspection. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 11:16 AM. LPA met with the facility staff who contacted the Administrator Gabriela Visovan. The Administrator arrived to the facility at approximately 11:45 AM entrance interview conducted and the reason for the visit was explained. The following was observed: RECORD REVIEW: Record review began at approximately 11:35 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation and signatures. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at 12:59 AM. Medications are stored centrally and securely in the medication room. Medications for five (5) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The last emergency disaster drill was conducted 06/10/2025. The facility’s emergency disaster plan is up to date and adequate. Both the infection control plan and emergency disaster plan are reviewed/updated annually by the facility’s Administrator. No deficiencies were cited at the time of the visit. Exit interview conducted. And a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 01:30 PM. LPA met with the facility Administrator Gabriela Visovan, entrance interview conducted and the reason for the visit was explained. Beginning at 01:33 PM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are twenty-seven (27) bedrooms in the facility; all are designated for resident use. LPA and facility Administrator toured ten (10) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS: Each bedroom in the facility has an attached private resident bathroom. Additionally, there is a shared resident bathroom and a shared shower room in the hallway of the facility. LPA and Administrator observed ten (10) private resident bathrooms, the shared resident bathroom and the shared shower room. Bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed next to all toilets and in all showers and all were properly secured. The water temperature was measured between 108.5 and 110.5 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C. COMMON AREAS: This includes the common activity room, hallway, and dining room areas. LPA observed the common activity room to be clean and properly furnished at the time of the visit. The common activity room contained a television and activities for residents’ use. The dining room contained adequate seating and was observed to be clean. Cameras were observed in the common areas and hallways throughout the facility. LPA observed the hallway to contain a dry food storage room, the locked medication room, the Administrator’s office, the common resident bathroom, and the shower room. Additionally the hallway was observed to contain additional fire extinguishers, the activity calendar, emergency exit sketches, and other required postings. The LPA observed fire extinguishers throughout the facility to be fully charged and last serviced on 02/14/2025. Smoke detectors and carbon monoxide detectors were last tested on 04/03/2025 and were functional at the time of the test. KITCHEN: The LPA observed the kitchen area to be clean and inaccessible to clients in care. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days’ perishable and seven (7) days non-perishable food. The facility has an adequate supply of emergency food and water. The LPA observed one (1) designated cleaning supply cabinet to be locked and inaccessible to residents. The cleaning supplies were stored separately from food and cooking utensils. OUTDOOR SPACE: The outdoor area has sufficient space for outdoor activities. The patio was observed to contain adequate patio furniture including shaded tables and chairs for residents’ use. LPA observed the locked laundry room to contain detergents and other cleaning supplies. LPA observed a locked storage room to contain tools, care supplies, and other chemicals. The patio of the facility has a small water fountain. The facility has an emergency exit gate, LPA observed clear passageways for emergency exit use. INTERVIEWS: LPA interviewed three (3) staff and three (3) residents. All residents stated that staff treat them well and are attentive to their needs. Residents interviewed did not have concerns with the quality of care they received at the facility. All staff interviewed were knowledgeable on their roles and responsibilities, the residents’ rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s current liability insurance, employee roster, resident roster, fire alarm test record, and worker’s comp insurance. Continued on LIC 809C. Due to time constraints LPA will return at a later date to conduct resident and staff file reviews, a medication audit, and a review of the facility’s emergency disaster plan and infection control plan. No deficiencies were observed during today’s inspection. Exit interview conducted. And a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 29, 2025

Allegation investigated: Facility does not provide resident with clean and comfortable mattress. Facility staff has threatened resident with eviction if resident complains to licensing agency.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 9:35 AM. LPA met with facility staff who contacted the facility Administrator Gabriela Visovan via phone call. The Administrator arrived to the facility at approximately 09:55 AM. the reason for the visit was explained and entrance interview was conducted. During today’s visit LPA conducted a physical plant tour, interviewed five (5) residents, and interviewed the facility Administrator between 09:55 AM and 11:30 AM. Continued on LIC-9099C Unsubstantiated The allegation of “Facility does not provide resident with clean and comfortable mattress” alleges that the facility did not provide a resident with an acceptable mattress. An interview with Resident #1 (R1) revealed that R1 had been sleeping on three (3) sleeping mats for the past six (6) months. R1 stated that they informed the Administrator that their previous mattress was not comfortable so they replaced it with the three (3) sleeping mats. R1 confirmed that the Administrator replaced the mats with a new mattress about 4-5 days ago. The interview with the Administrator revealed that they have replaced the mattress for R1 on five (5) separate occasions. The Administrator stated that R1 had their prior mattress swapped out for the three (3) mats around November 2024. The Administrator stated that the order of the three (3) mats on R1’s bed was, hospital bed mattress, egg crate mattress, gel mattress topper. The Administrator stated that during the time R1 had the three mats they had not informed the front office that they wished for a new mattress. The Administrator stated that when R1 informed them that they did not like the three (3) mats about a week ago they immediately replaced the mats with a new mattress. Interviews with four (4) additional residents did not reveal concerns with the mattresses provided. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of facility does not provide resident with clean and comfortable mattress. Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Facility staff has threatened resident with eviction if resident complains to licensing agency” alleges that the facility threatened to evict a resident for filing a complaint with Community Care Licensing Division (CCLD). During the interview with R1 they stated, “They didn’t threaten to evict me, that is not true.” During the interview with the Administrator, they recalled the interaction with R1 and stated that the resident approached the Administrator and asked for an orthopedic mattress. The Administrator informed R1 that, “We don’t provide orthopedic mattresses, if you would like one you will have to ask you family to buy you one.” R1 replied, “Well I’m going to complain.” To which the Administrator responded, “Okay, go ahead.” Additionally, interviews with four (4) additional residents did not reveal concerns regarding threats of eviction for reporting complaints to CCLD. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of facility staff has threatened resident with eviction if resident complains to licensing agency. Therefore, the allegation is deemed Unsubstantiated at this time. No deficiencies were observed during today’s inspection. A copy of the report was printed and exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 29-AS-20250107141159

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 08:31 AM. LPA contacted the facility administrator Gabriela Visovan via telephone call. Facility administrator arrived to the facility at approximately 08:50 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 08:52 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are twenty-seven (27) bedrooms in the facility; all are designated for resident use. LPA and facility administrator toured five (5) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS: Bathrooms are attached individually to resident rooms. LPA and administrator observed five (5) resident bathrooms. Bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed next to all toilets and in all showers and all were properly secured. The water temperature was measured between 105.4 and 109.7 degrees Fahrenheit, which is in compliance with regulation. COMMON AREAS: This includes the common room and dining room areas. LPA observed common room to be clean and properly furnished at the time of the visit. The Dining room contained adequate seating and was observed to be clean. Cameras were observed in the common areas and hallways throughout the facility. The LPA observed fire extinguishers throughout the facility to be fully charged and serviced on 02/17/2024. Smoke detectors and carbon monoxide detectors were last tested on 7/31/2024 and were functional at the time of the test. Report Continued on LIC 809-C KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The facility has adequate supply of emergency food and water. The LPA observed one designated cabinet where cleaning supplies are stored locked and inaccessible to residents. OUTDOOR SPACE: The outdoor space has sufficient patio furniture including shaded tables and chairs for resident use LPA observed the laundry room to be locked and contain detergents and other cleaning supplies. The facility has an emergency exit gate, LPA observed clear passageways for emergency exit use. RECORD REVIEW: Record review began at 09:35 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at 10:35 a.m. Medications are stored centrally and securely in the medication room. Medications for five (5) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 06/19/2024. The facility’s emergency disaster plan is up to date and adequate. INTERVIEWS: LPA interviewed five (5) staff and five (5) residents. All residents interviewed stated that the food was of good quality and is provided in sufficient amounts. All residents stated that staff treat them very well and are attentive to their needs. All staff interviewed were knowledgeable on resident rights, their roles and responsibilities, the different forms of abuse and the appropriate reporting procedures for suspected abuse. Report Continued on LIC 809-C During today’s visit LPA obtained a copy of the facility’s updated LIC500, surety bond, resident roster, and liability insurance. No deficiencies were cited at the time of the visit. Exit interview conducted. And a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 16, 2024