198602547-9-19-2023-28-AS-CWOG-CVTUSZ-20230919155109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602547
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:51:46 PM

Document Has Been Signed on 09/19/2023 03:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOLY HILL INC-SOMERSET HOME		FACILITY NUMBER:	198602547
ADMINISTRATOR:	SANTOS, MARIA TERESA F		FACILITY TYPE:	735
ADDRESS:	9883 SOMERSET BLVD		TELEPHONE:	(562) 506-5010
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 3		CENSUS: 2	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Christeann Santos		TIME COMPLETED:	04:15 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) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Juvy Biala and explained the reason of the visit. Shortly after, the administrator in training Christeann Santos and Jeff Jin arrived and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults, age range 18 through 59, 3 Non ambulatory and hospice waiver for 1. The facility is licensed as a Level 4I home vendored by Harbor Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and the facility includes three clients bedrooms, two clients bathrooms, kitchen, dining area, living room and detached garage with a laundry room. Each client has one bed, one chair, one night stand, required furniture and beddings and sufficient lighting and closet space. The two client bathrooms are clean, sanitary and in a good working condition. The hot water temperature in two bathrooms were tested between 110.3 and 112.8 degrees F. which are within the Title 22 regulation. All the appliances in the kitchen and living room are working probably. The sharp knives and utensils are stored and locked in the kitchen drawer. The chemicals and all cleaning supplies are stored and locked under the sink. The extra linen are stored in the hallway cabinet. The extra personal hygiene products are stored in the kitchen drawer near the staff office. LPA also inspected the smoke detectors and they are working well.(See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-SOMERSET HOME	FACILITY NUMBER: 198602547
	VISIT DATE: 09/19/2023

NARRATIVE

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The carbon monoxide detector is mounted on the wall near bedroom#1 and #2 and working good. The hallway light is always on during the night time. The facility also has a landline telephone system.

3. Operational Requirement: The facility is licensed for three (3) non-ambulatory clients and currently the facility has two non-ambulatory clients in the facility. The last fire drill was conducted on 09/08/23. The facility does have patio area with shaded area with table and chairs for clients to utilize the outdoor activity.

4. Staffing: The facility has sufficient staffing in the facility. The NOC shift staff has the required training for facility planned emergency procedure training.

5. Personnel Record-Training: The staff files are stored in the cabinet at the staff office near the kitchen. All the staff are over 18 years old, associated with the facility and criminal background cleared. All the staff files have the required the documents which include health screening, TB Test result, required training hours and updated first aid certificate. The facility administrator is Maria Teresa Santos and her administrator certificate expiration date on 4/27/25.

6. Client's Right-Information: Currently no clients is required postural support in the facility. The facility would provide at least one internet access device if needed.

7. Client's Record-Incident Reports: The clients files are stored in the cabinet at the staff office near the kitchen and all client's files are included: face sheet, admission agreement, physician report, TB test result, ambulatory status, functional capabilities assessment, medication list and Individual Program Plan (IPP).

8. Food Service: Currently no client in the facility required modified diet, only one client would have to be chopped food and Thick-it. The facility has two days perishable and seven days Non perishable food supply in the facility.

9. Health Related Services: The clients medication are centrally stored and locked in the cabinet in the staff desk and they are all seemed accurate and updated and they all have 30 days supply of medication.

10. Incidental Medical Services: Currently no client in the facility is under prohibited health condition or restricted health condition.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-SOMERSET HOME	FACILITY NUMBER: 198602547
	VISIT DATE: 09/19/2023

NARRATIVE

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11. Disaster Preparedness: The facility has an updated emergency disaster plan and dated on 3/3/23. The last fire/emergency drill was conducted on 09/08/23 and The facility has two alternative temporary shelter location.

12. Emergency Intervention: The facility does not use any restraints on clients but all staff have the updated CPI training certificate.

No deficiencies observed during the visit.

Exit Interview conducted and a copy of the report was provided to Christeanne Santos.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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