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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606335
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:45:20 PM

Document Has Been Signed on 08/11/2022 01:45 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HILLVIEW RESIDENTIAL CENTER, BUILDING CFACILITY NUMBER:
197606335
ADMINISTRATOR:JACK AVILAFACILITY TYPE:
735
ADDRESS:12408 VAN NUYS BLVD., BUID. CTELEPHONE:
(818) 896-1161
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 15CENSUS: 9DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nicole Sosa - AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Nicole Sosa. Purpose of visit was stated. LPA observed that all nine (9) residents were at the facility during visit.

A tour of the physical plant was conducted at 9:30 AM and the following were noted:
munity buildings. The main door is the only entrance being utilized for entry. There is a sign on the door that
Entry is only through the main gate along the main road and needed to call in before entry, as this is a gated com everyone entering at the facility must wear mask and must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by the staff upon entry. All staff were observed to be wearing mask.

The facility had submitted and approved Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the other building. The facility has sufficient stock of PPE in the storage room.

The facility is part of series of building inside the compound. It is a one storey stand alone building and has five (5) shared client bedrooms and three (3) bathrooms. There are additional three (3) vacant room designated for isolation. There is also a bathroom designated for staff use only.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HILLVIEW RESIDENTIAL CENTER, BUILDING C
FACILITY NUMBER: 197606335
VISIT DATE: 08/11/2022
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.

Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the maintenance room that could only be accessed by maintenance staff. Food: The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. All the food however are being prepared off site and just brought to the facility. Temperature of facility wall thermostat is set at 74.0°F and observed to be within the required range. Fire extinguisher: There are fire extinguishers all over the facility, one (1) in the kitchen, one (1) in the hallway in between bedrooms and another at the dining area.. Extinguishers were observed to be operable and last inspected on 01/03/2022. Smoke and carbon monoxide alarms are tested and observed to be operable.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.

Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at a range of 113.5°F to 118.9°F and within the required range.

Laundry room is located in the bedroom hallway. Cleaning solutions and laundry detergents are observed kept in the locked cabinet in the locked laundry room.

Medication was observed to be inaccessible and stored in a secured cabinet in the office. There is a complete First Aid kit attached to the medication cabinet.

There was no immediate health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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