191592309-9-22-2023-28-AS-CWOG-CVWUZF-20230922160127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592309
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:02:09 PM

Document Has Been Signed on 09/22/2023 04:02 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PADUA VILLAGE, INC. - HILLSDALE HOME		FACILITY NUMBER:	191592309
ADMINISTRATOR:	CHERROL ALLAN		FACILITY TYPE:	735
ADDRESS:	1226 HILLSDALE DR.		TELEPHONE:	(909) 626-4799
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 6		CENSUS: 6	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maria Devore		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Maria Devore explained the reason of the visit and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults, age range 18 through 59, 4 ambulatory and 2 non-ambulatory. The facility is licensed as a Level 2 home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room/Staff Office, TV room, dining area, kitchen, puzzle room/laundry room, 5 clients bedrooms and 3 clients bathrooms. Bedroom#1, #2, #4, #5 has one bed, one chair, one drawer, one night stand, required beddings and furniture and sufficient closet space and lighting. Bedroom#3 has two beds, chair, two night stands, two drawers and required beddings and furniture and sufficient lighting and close space. The three clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in three bathrooms were tested between 110.6 and 111.0 degrees F which are within Title 22 regulation. The appliances in the kitchen and living room/TV room are working probably. The sharp knives are stored and locked in the kitchen drawer. The chemicals and cleaning supplies are stored and locked under the sink and cabinet in the laundry room. The extra personal hygiene are stored in the kitchen cabinet and the extra linen are stored in the hallway cabinet.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PADUA VILLAGE, INC. - HILLSDALE HOME	FACILITY NUMBER: 191592309
	VISIT DATE: 09/22/2023

NARRATIVE

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The facility would turn on the hallway light for client to have access to the nonprivate bathrooms during night time. LPA inspected the carbon monoxide detectors and its mounted on the hallway and its working well. The facility also has a land line telephone. The walkway, passageway and patio are free of obstruction.

3. Operational Requirement: The facility is cleared for 4 ambulatory and 2 non-ambulatory. Currently all the clients in the facility are ambulatory. The last fire drill was conducted on 09/07/23. The facility has a outdoor patio with tables and chairs for client to utilize the outdoor activities. The client is able to attend community activities if there's a chance or opportunity.

4.Staffing: The facility has sufficient staffing in the facility. The NOC shift staff does have the required facility planned emergency procedure training.

5. Personnel Record-Training: The staff files are stored and locked in the cabinet in the puzzle room/laundry room. All staff are over 18 years old, associated with the facility and criminal background cleared. LPA inspected the staff files and they all have the required documents which include: health screening, TB test result, update first aid certificate and required training hours. The facility administrator is Maria Devore and administrator certificate expired on 05/23 but the administrator certificate is pending at our CCL system list at the present time. The administrator has an update HIV and TB training certificate.

6. Client's Right: Currently the facility has no client is required postural support. The facility does provide internet service at least one internet access device for client to use.

7. Client's Record-Incident Reports: The clients files are stored in the bookcase in between the TV room and formal living room. LPA reviewed all clients files which have all the required documents and includes: face sheet, admission agreement, functional capabilities assessment, updated physician report and TB test result, ambulatory status, medication list and Individual Program Plan (IPP)

8. Food Service: The facility has sufficient food supply include two days perishable and seven days non-perishable. The food are stored probably in the facility. There's no client required modified diet that prescribed by the doctor.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PADUA VILLAGE, INC. - HILLSDALE HOME	FACILITY NUMBER: 191592309
	VISIT DATE: 09/22/2023

NARRATIVE

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9. Health Related Services: The medication is centrally stored and locked in the kitchen cabinet. LPA inspected all six (6) clients medication and they all seemed accurate and updated. All clients have 30 days supply of medication.

10. Incidental Medical Services: The facility currently has one client is under restricted health care plan. The restricted health care plan is updated on 04/2023 and approved by the doctor and regional center and all staff received the required training. No client is currently under prohibited health condition in the facility.

11. Disaster Preparedness: The emergency disaster plan (LIC610D) is updated on 09/22/23 and the last fire/emergency drill was conducted on 09/07/23 and the facility has two alternative shelter location.

12. Emergency Intervention: The facility does not use any restrain on clients but staff does have updated CPI training hours.

No deficiencies were observed during the visit.

Exit Interview Conducted and a copy of the report was provided to the administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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