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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592309
Report Date: 09/15/2025
Date Signed: 09/15/2025 04:11:44 PM

Document Has Been Signed on 09/15/2025 04:11 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PADUA VILLAGE, INC. - HILLSDALE HOMEFACILITY NUMBER:
191592309
ADMINISTRATOR/
DIRECTOR:		MARIA DE VOREFACILITY TYPE:
735
ADDRESS:1226 HILLSDALE DR.TELEPHONE:
(909) 626-4799
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: DATE:
09/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:51 AM
MET WITH:Maria De VoreTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced required annual inspection visit and was greeted by Administrator Maria De Vore and conducted a tour of the facility approximately at 9:40am. LPA Madyun explained the purpose of the visit. The facility is a single story home located on a residential street.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment Safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger, were observed to be inaccessible to clients. LPA Madyun observed a carbon monoxide detector and smoke alarms throughout the facility. LPA Madyun inspected five (5) client bedrooms and three (3) bathrooms in which one (1) is a shared Jack and Jill. All client bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be 109.6-118.7 degrees which is within the required 105-120 degrees Fahrenheit.

Food Service: LPA Madyun observed sufficient supply of non-perishables for seven days and perishable foods for a minimum of two days. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degrees Fahrenheit (-17.7 degree C), and refrigerators with maximum temperature of 40 degrees Fahrenheit. (4 degree C). Kitchen water temperature measured to be 112.2 degrees Fahrenheit which is within the required 105-120 degrees Fahrenheit.


Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PADUA VILLAGE, INC. - HILLSDALE HOME
FACILITY NUMBER: 191592309
VISIT DATE: 09/15/2025
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Residents Rights-Information: LPA Madyun observed the following postings in a common area of the facility: Complaint Poster (PUB 475), personal rights, and non-discrimination notice. LPA Madyun observed the facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC 610D/9 pages) in place last revised August 2025. Last documented emergency drills were conducted on 07/10/25. LPA Madyun observed facility sketch with exits and emergency exit routes of the facility. LPA Madyun observed emergency food supply located in the activity room/laundry area/cupboard storage.

Health Related Services/Incidental Medical Services: The clients medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Maria De Vore #7007866735 Expires 05/13/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Madyun observed required annual training, First Aid and CPR for one (1) out of six (6) personnel records reviewed. LPA Madyun observed TB testing results, Health screening, fingerprint clearance and job application for one (1) out of the six (6) personnel records reviewed. Due to time constraint LPA will return a later date and time for a continuation visit to review staff files and conduct staff interviews.

Infection Control: The staff practice appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place revised September 2025 and will provide via email.



Operational Requirements: The facility is licensed to serve Developmentally Disabled Adults age range 18- 59 years old. The facility may serve four (4) ambulatory and two (2) non-ambulatory clients. All clients in facility are receiving services from San Gabriel/Pomona Regional Center.

Client Records/Incident Reports: LPA reviewed five (5) of five (5) client files in care. Client files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal, Individual Program Plan, and Resident Rights were observed. Due to time constraint LPA will return a later date and time for a continuation visit to conduct client interviews.

No deficiencies were observed during visit. Exit interview conducted with Maria De Vore and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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