197607211-3-23-2023-28-AS-BTAO-CQ7VBZ-20230323161822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607211
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:18:34 PM

Document Has Been Signed on 03/23/2023 04:18 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:	HILLSIDE HOME FOR ELDERLY		FACILITY NUMBER:	197607211
ADMINISTRATOR:	MARICIEL GAMBOA		FACILITY TYPE:	740
ADDRESS:	1025 LEANDRA LANE		TELEPHONE:	(626) 802-5613
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91006
CAPACITY:	6	CENSUS: 4	DATE:	03/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Mariciel Gamboa, Administrator		TIME COMPLETED:	04:30 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) Tao conducted an unannounced annual inspection visit. Upon arriving at the facility, LPA met with Mariciel Gamboa, Administrator. LPA explained the purpose of the visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, and approved for six (6) non-ambulatory residents. Facility may retain four (4) hospice residents. Facility have 24 hour awake staff. Currently, all four (4) residents are non-ambulatory. Annual fees are current. Administrator certificate is current and expire on 8/31/23. During the visit, the care tool was used, a tour of the facility was conducted, medication was reviewed, staff was interviewed, residents were interviewed, and food supply was reviewed. The facility is located in a residential area. A physical tour was conducted. The facility is a single-story house includes: living room, dining area, attached garage/storage, kitchen, pantry, TV room, three (3) resident bedrooms, two (2) bathrooms and staff office/lounge room. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 117.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed.. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature for residents. Sufficient supply of perishable and nonperishable foods were observed. Smoke detectors and carbon monoxide detectors are operable. Smoke detectors in the hallway and bedrooms are hard wired. Fire extinguisher was mounted in the kitchen wall and fully charged. (-continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HILLSIDE HOME FOR ELDERLY	FACILITY NUMBER: 197607211
	VISIT DATE: 03/23/2023

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The first aid kit is fully stocked. All mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents.

No deficiency was observed.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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