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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608283
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:27:24 AM

Document Has Been Signed on 11/10/2022 10:27 AM - 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HILLTOP HAVEN 2FACILITY NUMBER:
197608283
ADMINISTRATOR:ERWIN DUFFELSFACILITY TYPE:
740
ADDRESS:6531 GLORIA AVENUETELEPHONE:
(818) 474-9671
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 4DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Tom StilesTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator Erwin Duffels and explained the reason for the visit. Duffels stated he was unable to stay for the inspection , but facility designee Tom Stiles will join the inspection with LPA and sign for the report in his place.  

Facility has (4) resident bedrooms. (2) of the bedrooms are private resident rooms. Hallway bathroom is designated for common use. All resident rooms have a private bathroom, with the exception of resident room #4. . 

At approx. 08:30am, LPA toured the facility with Stiles.  The kitchen appeared to be relatively  clean at this time and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer in the office area on the left side of the kitchen. LPA observed drawer to be locked at this time.  Laundry area was located next to the kitchen. Cleaning products were observed to be inaccessible at this time.

Dining room furniture appeared to be relatively clean and functional at this time. At 8:30am, LPA observed (1) resident eating breakfast. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident.  The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed five (5) bedrooms that includes a staff room. Staff room was observed to be inaccessible to clients in care and  empty at time the of the visit.   Extra linen are kept in a cabinet in the hallway. LPA observed a sufficient supply of linen and  personal hygiene  supplies in the hallway closet nearest to the  common bathroom.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HILLTOP HAVEN 2
FACILITY NUMBER: 197608283
VISIT DATE: 11/10/2022
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Continued from 809

LPA observed all bathrooms to be relatively  clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom  between 105 - 120 degrees Fahrenheit.

The living room was  checked for cleanliness and furniture was checked for functionality during time of visit. Furniture appeared to be relatively clean and functional at this time.  Hallway closet by entry door was observed to store medications, first aid, and PPE. Closet was observed to be inaccessible to residents in care at this time. Client files were observed locked in a cabinet next to staff room by the dining room.   Fire extinguisher were observed to be fully charged and purchased  in July of 2022.  LPA observed  a 30 day supply of PPE stored easily in multiple locations throughout the facility.

Outdoor Area:  There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises.  LPA did not observe any obstructions to emergency exits at this time.  The backyard and exterior area of the facility is completely fenced with a self-latching gate at the facility entrance. There is a detached garage located in the rear of the facility. LPA observed it to store miscellaneous supplies for facility use at this time.

The LPA spoke with Tom regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate bedroom 2 as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns.  The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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