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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602547
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:32:40 PM

Document Has Been Signed on 09/20/2022 01:32 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-SOMERSET HOMEFACILITY NUMBER:
198602547
ADMINISTRATOR:SANTOS, MARIA TERESA FFACILITY TYPE:
735
ADDRESS:9883 SOMERSET BLVDTELEPHONE:
(562) 506-5010
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 3DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Roda Dizon, AdministratorTIME COMPLETED:
01:45 PM
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On 9/20/22 at 11:35 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Roda Dizon who assisted with today’s visit.

The facility is licensed to serve 3 non-ambulatory clients between the ages of 18 and 59 years old, with a hospice waiver for 1. They are vendored through Harbor Regional Center. The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 3 bedrooms, 2 bathrooms, office space, backyard with shaded area with a detached shed and detached garage. Fire extinguisher observed kitchen fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.

LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Report continued 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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-SOMERSET HOME
FACILITY NUMBER: 198602547
VISIT DATE: 09/20/2022
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA observed a hole on the wall inside of C1 bedroom. Administrator stated C1 created the hole while rocking back on the chair. The administrator stated staff didn’t notice the hole because the chair blocked the hole. LPA took a photo of the hole during the tour. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. LPA was not able to gain access to garage and shed due because the key is located with the licensee. Administrator stated the garage has been converted to licensee office and the shed is currently being used for storage. The resident bathrooms are clean, and showers have grab bars. The hot water temperature measured at 108.6- 109.8 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility. Medications reviewed for all clients and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6050027735 expire 1/25/2024. Last emergency disaster drill 9/19/22.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2022 01:32 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 09/20/2022 at 01:07 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-SOMERSET HOME
FACILITY NUMBER: 198602547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, empolyees and visitiors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, when LPA observed a hole in the wall in C1 bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2022
Plan of Correction
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Licensee will ensure that the facility is in good repair at all times. The licensee will fix the hole in C1 bedroom and send a photo to LPA by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022


LIC809 (FAS) - (06/04)
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