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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602545
Report Date: 10/06/2022
Date Signed: 10/06/2022 02:35:02 PM

Document Has Been Signed on 10/06/2022 02:35 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:HOLY HILL INC-MAPLEDALE HOMEFACILITY NUMBER:
198602545
ADMINISTRATOR:SANTOS, MARIA TERESA FFACILITY TYPE:
735
ADDRESS:11559 MAPLEDALE STREETTELEPHONE:
(562) 506-5010
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 3CENSUS: 3DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator: Roanld DinoTIME COMPLETED:
02:45 PM
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On 10/6/2022 Licensing Program Analyst (LPA) Ashley Calderon made an unannounced visit to Holy Hill Inc-Mapledale Home. The purpose of today’s visit was to conduct the Required 1 Year inspection. On today’s visit LPA Calderon was allowed entry into the home and met Caregiver Karen De Los Reyes. Caregiver Benita Guinto was also present. The home is licensed for 3 non-ambulatory clients. Facility also has a hospice waiver for 1 client, no client on hospice at the time. The last fire drill was conducted on 09/01/2022.

At 9:40 pm LPA Calderon conducted the tour of the physical plant along with De Los Reyes. The one story home consists of 3 client bedrooms, 2 bathrooms, living room, dining room, kitchen, backyard and the attached garage that is used for storage and remains locked. LPA and De Los Reyes first toured the kitchen the hot water temperature read at 108.4, the refrigerator had sufficient non-perishable and perishable foods, fire extinguisher is charged, sharp items, cleaning supplies and medication cabinet that are all stored in the kitchen cabinets were locked and inaccessible to clients. Common bathroom hot water read at temperature of 106.3, hallway had laundry room which laundry is done by staff, oxygen monoxide and fire alarm system are properly working. C1 bedroom observed it to be within Title 22 regulation. C2's bedroom was observed it to be within Title 22 regulation as well as C3's bedroom. All contained proper bedding, bed linen, comforters, pillows, adequate lighting, space for clothing and personal items, a chair and rooms are clean and in good repair. C3's room has a private bathroom hot was temperature read at 109.7.

Home had a comfortable temperature of 76 degrees F, floor in good repair, all rooms remain clean , bathrooms well stocked, sufficient toiletries for clients when needed is available. LPA Calderon toured the outside grounds and no bodies of water were observed. A shaded area with plenty of seating for clients was observed. Exits/ Walkways around the home were free of debris and hazards.

See 809C for continuation page...

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY HILL INC-MAPLEDALE HOME
FACILITY NUMBER: 198602545
VISIT DATE: 10/06/2022
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LPA Calderon conducted the review of client medications along with Caregiver De Los Reyes. Client medications and medication documentation were found to be in order.

At 10:15pm Administrator Ronald Dino arrived later to assist LPA Calderon with the visit. LPA Calderon and Dino conducted the review of staff records. LPA reviewed 6 staff records, and found one staff who was not associated/ cleared ,see 809D.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 1, Article 3. Civil Penalty totaling at $500.00 was assessed today.

An exit interview was held with Administrator Ronald Dino and a copy of this reports were given: LIC 809 , LIC 809c, LIC 809D ,LIC 421BG , and Appeal Rights were provided at the time of the visit.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2022 02:35 PM - It Cannot Be Edited


Created By: Ashley Calderon On 10/06/2022 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOLY HILL INC-MAPLEDALE HOME
FACILITY NUMBER: 198602545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
(e) All individuals subject to a criminial background review pursuant to Health & Safety Code Section 1522 shall prior to work, residing, or volunteering in a licensed facility.
(2) Request a trasnfer of a current criminial record clearance as specified in Section 80019(f).




This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation , staff file review and interview, the licensee did not comply with the section cited above which is S3 was not associated/ had a background clearance.
POC Due Date: 10/07/2022
Plan of Correction
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Administrator Dino notified staff is not able to return to the facility until assosicated and cleared in LIS/ Guardian, Dino will read title 22 on Criminial Record Clearance, administrator will process paper work, create a Guardian aacount and will follow up,.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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