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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602546
Report Date: 10/10/2022
Date Signed: 10/10/2022 01:09:05 PM

Document Has Been Signed on 10/10/2022 01:09 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-BENFIELD HOMEFACILITY NUMBER:
198602546
ADMINISTRATOR:SANTOS, MARIA TERESA FFACILITY TYPE:
735
ADDRESS:14732 BENFIELD AVETELEPHONE:
(562) 506-5010
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administratior - Ronald DinoTIME COMPLETED:
01:15 PM
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On 10/10/2022 Licensing Program Analyst (LPA) Ashley Calderon made an unannounced visit to Holy Hill Inc-Benfield Ave. 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 Renato Ignacio. Staff Census :4. The home is licensed for 3 non-ambulatory clients and 1 ambulatory, Capacity of 4/ Census: 3 . Facility also has an hospice waiver for 1 client, no client on hospice at the time. The last fire drill was conducted on 10/06/2022.

LPA Calderon conducted the tour of the physical plant along with Dino. The one story home consists of 3 client bedrooms, 2 bathrooms, living room, dining room, kitchen, backyard, 1 backhouse containing 2 rooms, and a restroom that is used for storage and remains locked and inaccessible to the clients. Backhouse is on facility sketch LIC 999 labeled as Rumpus Room. There is a detached garage that is used for storage and remains locked. LPA and Dino first toured the kitchen the hot water temperature read at 111.8, 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 106.0, C1 and C2 bedroom 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 108.5.

Home had a comfortable temperature of 73 degrees F, floor in good repair, all rooms remain clean , bathrooms well stocked, sufficient toiletries for clients when needed are 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 and a laundry area and sink temperature of 116.0. Exits/ Walkways around the home were free of debris and hazards. Oxygen monoxide and fire alarm systems are properly working. See 809C for continuation page...

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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-BENFIELD HOME
FACILITY NUMBER: 198602546
VISIT DATE: 10/10/2022
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LPA Calderon conducted the review of client medications along with Dino and Owner Edgardo Francisco whom arrived at 11:30 am . Client medications and medication documentation were found to be in order. LPA Calderon and Dino conducted the review of staff records. LPA reviewed 4 staff records. LPA Calderon assisted Francisco in Guardian accessibility.

No deficiencies cited under California Code of Regulations Title 22.

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

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

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

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