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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592309
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:08:38 PM

Document Has Been Signed on 09/15/2022 02:08 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PADUA VILLAGE, INC. - HILLSDALE HOMEFACILITY NUMBER:
191592309
ADMINISTRATOR:CHERROL ALLANFACILITY TYPE:
735
ADDRESS:1226 HILLSDALE DR.TELEPHONE:
(909) 626-4799
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Nicole Lian, staff in charge, DSP
Maria Devore, administrator		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with DSP Nicole Lian, who assisted with the visit. LPA spoke with administrator, Maria Devore, over the phone. The facility served four (4) ambulatory and two (2) non-ambulatory developmentally disabled adults. Currently all clients are ambulatory and placed by San Gabriel/Pomona Regional Center. Administrator certificate's expiry date on 05/13/23. Annual fees are current. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

This is a single story home which consists of five (5) clients' bedrooms, three (3) bathrooms, living room, front room/staff office area, dining area, kitchen, attached garage used as game /exercise room with a back yard with tables and chairs. Stove burners, oven, microwave, washer, and dryer are all working well. There are two refrigerators in the home, one in the kitchen and one in the garage for additional food storage. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser, and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Hot water temperature was measured at 114.0 degrees Fahrenheit.

The smoke detectors are located in each bedroom and common area and they are all working properly. The carbon monoxide detectors are located on the hallway mounted on the wall and they are all working well. (-continued in LIC 809C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PADUA VILLAGE, INC. - HILLSDALE HOME
FACILITY NUMBER: 191592309
VISIT DATE: 09/15/2022
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Medications are centrally stored and locked. Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged and last service is 9/6/22. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill is conducted on 06/28/22.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted and report LIC 809s was discussed and provided to Nicole Lian, DSP, whose signature on this form confirm receipt of these documents. Appeal right was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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