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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 09/01/2022
Date Signed: 09/13/2022 04:06:50 PM

Document Has Been Signed on 09/13/2022 04:06 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:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:BITLER, MAUREEN H.FACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: 62DATE:
09/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Resident Care Coordinator, Angelica White TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on September 1, 2022 to conduct a Case Management visit. LPA Hurt identified herself and discussed the purpose of the visit with the Resident Care Coordinator Angelica White.

LPA Hurt recently conducted an over the phone interview with Resident 1 who stated the facility Administrator mentioned allowing Resident 2 to be a representative from the first floor (memory care) at facility Resident council meetings. Resident 1 stated the Executive council of the Resident Council which is comprised of residents from the second, third, and fourth floors initially ignored the Administrators request. Resident 1 stated eventually Resident 2 did join the meetings as a representative of the first floor, but the Executive Council voted that it not be allowed. Based on this it appears Resident 2's rights were violated by the facility Executive council as he/she were not being allowed to join in as Representative of the first floor at the Resident Council Meetings.

The following Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Resident Care Coordinator Angelica White and a copy of this report left at the facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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Document Has Been Signed on 09/13/2022 04:06 PM - It Cannot Be Edited


Created By: Sarah Hurt On 09/01/2022 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/15/2022
Section Cited
CCR
87468.1(a)

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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:The basic The following requirement has not been met as evidenced by:
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Administrator will provide training on Resident Personal Rights to facility staff and send proof of trainiing to LPA by 09/15/2022 POC date.
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Based on LPA interviews the faciltiy executive council voted to prevent Resident 2 from being on the facility Resident Executive council as a representative which poses a potential health, safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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