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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801723
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:06:35 PM

Document Has Been Signed on 06/14/2023 12:06 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BEACON HILLFACILITY NUMBER:
216801723
ADMINISTRATOR:BENOIT, WILSONFACILITY TYPE:
735
ADDRESS:826 HAYDEN AVE.TELEPHONE:
(415) 897-9716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee, Wally HyppoliteTIME COMPLETED:
12:15 PM
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Licensee, Wally Hyppolite. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory clients. Upon arrival, LPA was informed that there were 6 clients in care, with three out of the community attending Day Program, and three clients sleeping in their rooms. LPA was also informed that there was 1 staff member on site. Administrator, Wilson Benoit, arrived later during visit at approximately 10:00AM.

At approximately 9:30AM LPA reviewed the facility's staff roster with Licensee and found that all staff members were background cleared and associated to the facility per regulation. At approximately 9:40AM LPA conducted a walk-though of the facility with Licensee. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a two story building with 6 bedrooms, 2 bathrooms, a kitchen, dining room, multipurpose room, and staff rooms. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Facility has two fire extinguishers which were last inspected March 2023. Facility's smoke and carbon monoxide detectors were tested and operational. The last Emergency/Fire Drill was conducted January 2023.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEACON HILL
FACILITY NUMBER: 216801723
VISIT DATE: 06/14/2023
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Continued from LIC809

At approximately 10:30AM, LPA conducted a sample review of 2 client files and 2 staff files. Client and Staff files were all found to be well organized, thorough and contained the required documentation. P&I monies were documented, secure and not commingled. Staff files were all found to have First Aid and CPR certification. Administrator's Certificate for Licensee (6002802735) and Administrator (6006356735) were current with expiration dates of 06/25/2023 and 01/31/2025.
At approximately 11:00AM, LPA reviewed medications. All medications were found to be centrally stored and secure. At approximately 11:20AM, LPA conducted staff interviews.

LPA is requesting the following documents to update the facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)


Documents to be submitted to Community Care Licensing (CCL) by due date of Friday, July 14, 2023.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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