<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602546
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:57:41 AM

Document Has Been Signed on 07/19/2024 11:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOLY HILL INC-BENFIELD HOMEFACILITY NUMBER:
198602546
ADMINISTRATOR/
DIRECTOR:		SANTOS, MARIA TERESA FFACILITY TYPE:
735
ADDRESS:14732 BENFIELD AVETELEPHONE:
(562) 506-5010
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Ronald Dino TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Ronald Dino and the purpose of the visit was discussed.

The following twelve (12) tool domains were completed:
1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility only has an approved mitigation plan.

2. Physical Plant and Environmental Safety: The facility is a single-story home located in a residential neighborhood. There is currently three (3) individual client bedrooms, a living room, dining room, a kitchen which also functions as an office, one (1) shared client bathroom. Water temperature measured at 110 degrees all around. There is a front and back patio area which contains the facility’s washing and drying machines, and a detached garage which serves as a storage area for the facility. Each bedroom had required beds for each client, chairs, night stands, dressers and required bed linen and sufficient lighting and closet space. LPA observed extra linen and towels located on the 2nd floor. All the appliances in the kitchen are working properly. Facility has sufficient space for outdoor activities. No large bodies of water observed. Pathways, hallways and stairs are free of obstructions. LPA inspected the carbon monoxide and smoke detectors which were operable. Fire extinguishers was observed and they are up-to-date, charged and serviced. Last Fire Drill conducted on: 4/4/2024.

3. Operational Requirements: The facility is licensed for a capacity of four(4) of which three (3) may be non-ambulatory developmentally disabled adults, between the ages of 18-59. There are currently three (3) non ambulatory clients. Fire drills conducted quarterly. The facility has a shaded area for clients to use.

******Continued on LIC 809-C********
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2020
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY HILL INC-BENFIELD HOME
FACILITY NUMBER: 198602546
VISIT DATE: 07/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4.Staffing: The facility has sufficient staffing to provide care and supervision. Sufficient overnight staff observed on schedule. Training's for staff supervision protocols observed.

5.Personnel Records-Training: All the facility staff files are maintained in the facility. The Administrator certificate is currently pending renewal with the department. Administrator has required completed training's on file. LPA reviewed three (3) Staff files. Required documents observed on file for all.

6.Client's Right: The facility does not have any client with postural support at the present time. The facility does serve adults has internet service shall provide at least one access device.

7.Client's Records-Incident Reports: All the clients files are maintained in the facility. LPA reviewed three (3) clients files and they all have the required documents which are included: admission agreement, functional capabilities assessment, updated physician report, Individual Personalized Plan (IPP), ambulatory status and medication list ..etc

8.Food Service: Facility has sufficient food supply is stored in the kitchen and the garage consisting of: 2-day perishables, 7-day non-perishables. The refrigerator is maintained in the required temperature. All the food are stored probably.

9. Health Related Services: All the clients medication are centrally stored and inaccessible to clients in care. LPA inspected three (3) client medications. A medication error was observed and addressed.

10. Incidental Medical Services: The facility currently does not have any clients with any prohibited health condition or restricted health condition. There is a Hospice waiver for up to one (1) client but there are no clients on hospice.

11. Disaster Preparedness: The facility has an emergency and disaster plan in place. The facility has two appropriate temporary shelter location. Client emergency files are available when needed.

12. Emergency Intervention: The facility is not using any restraint in the facility.

Per Title 22 Regulations, no deficiency is being cited. Technical Assistance was provided regarding the Infection Control Plan. Exit interview conducted, a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2