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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602547
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:47:32 PM

Document Has Been Signed on 08/27/2024 12:47 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 HOMEFACILITY NUMBER:
198602547
ADMINISTRATOR/
DIRECTOR:		SANTOS, MARIA TERESA FFACILITY TYPE:
735
ADDRESS:9883 SOMERSET BLVDTELEPHONE:
(562) 506-5010
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 3DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Aurora Ortiz - Caregiver TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Aurora Ortiz (caregiver), shortly after Administrator Teresa Santos arrived to assist with the visit, the purpose for today’s visit was explained. The facility is licensed to serve (3) Non-Ambulatory Clients ages 18-50, and have a Hospice waiver for (1). There are (0) clients Hospice Services. All clients are serviced through Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: 3 Bedrooms, 2 Bathrooms, Living Room, Kitchen, Dining Area, Detached Garage with Laundry and Storage, Front Yard and Back Yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients, however, during tour LPA observed cleaning supplies stored in an unlocked cabinet in client bathroom along with the kitchen drawer that holds sharps/knives was unlocked during visit, details will be cited on the 809-D. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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: 08/27/2024
NARRATIVE
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 8/9/24.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Medication Training, Hospice Training and sufficient on-going training. There were 3 out of 4 staff files reviewed during todays visit that were missing First-Aid Certificates, details will be cited on the 809-D. 1 out of 4 staff were not associated to facility, however, administrator was able to show proof of criminal background clearance, citation details documented on 809-D. Teresa Santos maintains a valid certificate that expires on 4/27/2025.
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files with no issues. Facility is currently working with LPA for Age Waivers for clients at this facility as clients are above the age of 59 years.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers.
Incidental Medical & Dental: Staff designated to administer medication have the proper training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report and appeal rights were given to Teresa Santos.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/27/2024 12:47 PM - It Cannot Be Edited


Created By: Tena Herrera On 08/27/2024 at 12:19 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: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 as during facility tour with staff LPA observed a can of cleaning disinfectant "comet" to be in an unlocked cabinet in client restroom near main enterance, also LPA observed the kitchen drawer that holds knives/scissors to be unlocked, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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** staff removed cleaning disinfectant and stored with other locked cleaning supplies in kitchen cabinet once it was found, also staff locked kitchen drawer during visit*
Licensee/Administrator to conduct a training in proper storing of disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients, a copy of training materials and training log with participant list to be emailed to LPA by 9/10/2024.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 12:47 PM - It Cannot Be Edited


Created By: Tena Herrera On 08/27/2024 at 12:19 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: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 4 staff files reviewed did not have proof of association to facility, LPA also printed out a copy of association list from LIS where Staff was missing from as well, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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** Proof of criminal background clearance was provided to LPA during visit **
Administrator/Licensee to have staff associated to facility by POC due date, a copy of proof of association to be emailed to LPA as a means of correcting citation ans shall be provided to LPA by POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above 3 out of 4 staff files reviewed during visit were missing their valid First-Aid certificates, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Licensee/Administrator to have staff complete First-Aid training (if not already done so) and provide a copy of the valid CPR certificates to LPA by POC due date, staff missing certificates are (Lazo,Ortiz,Gerio).
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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