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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600141
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:48:30 AM


Document Has Been Signed on 10/03/2024 11:48 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HOLY HILL INC./CARFAX HOMEFACILITY NUMBER:
198600141
ADMINISTRATOR:FRANCISCO, ROBERTFACILITY TYPE:
740
ADDRESS:13831 CARFAX AVETELEPHONE:
(562) 867-3279
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:6CENSUS: 3DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Tiffany Kim - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Tiffany Kim and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and above. The facility currently has 3 Residents all of which are serviced through Harbor Regional Center.

The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms, 2 full bathrooms, living room, kitchen, dining area, laundry area, den, detached garage with office and tool shed used as storage.

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


Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and there is an Infection Control Plan maintained at the facility.
Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.
(Continued on LIC809-C)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY HILL INC./CARFAX HOME
FACILITY NUMBER: 198600141
VISIT DATE: 10/03/2024
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Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Tiffany Kim certificate expires on 3/7/2025.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 2 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 2 residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 6/8/2024.
Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to Tiffany Kim.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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