197607211-12-1-2023-28-AS-JVIS-CY4SUP-20231201131125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607211
Report Date: 12/01/2023
Date Signed: 12/01/2023 01:11:32 PM

Document Has Been Signed on 12/01/2023 01:11 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
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: 3	DATE:	12/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Administrator Mariciel Gamboa		TIME COMPLETED:	01:25 PM

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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Mariciel Gamboa. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. Infection Control Plan observed.

Operational Requirements:

A current Plan of Operation observed. Dementia Care Plan Observed
A fire clearance for 6 residents of which (6) may be non ambulatory
Hospice care waiver approved for up to four (4) resident.

Physical Plant/Environment Safety:

The facility is a single-story house includes: living room, dining area, attached garage/storage, front and backyard, kitchen, pantry, TV room, three (3) resident bedrooms, two (2) bathrooms and a staff room
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Personnel Records - Staff Training:

Administrator on file is current.
Staff have criminal background clearance and training.
Four (4) staff files were reviewed. Required training observed

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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: 12/01/2023

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Staffing:

Sufficient staff observed during visit

Resident Records - Incident Reports:

A total of three (3) resident files were reviewed.

Resident Rights - Information

Required postings observed

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Activities supply observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Incident Medical and Dental:

Emergency transportation available
First Aid Kid observed
(3) of (3) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.
Last Fire Drill on 10/17/23

Residents with Special Health Needs:

Needs and Services Plan and Appraisals are on file.
Currently (0) residents receiving hospice services.

Inspection Tool was completed and no deficiencies are being cited on todays visit.
Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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