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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000012
Report Date: 05/10/2022
Date Signed: 05/10/2022 10:46:20 AM


Document Has Been Signed on 05/10/2022 10:46 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HILLHURST MANORFACILITY NUMBER:
306000012
ADMINISTRATOR:SCHENKELBERG, PETER J.FACILITY TYPE:
740
ADDRESS:24052 HILLHURSTTELEPHONE:
(949) 357-6666
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Peter SchenkelbergTIME COMPLETED:
10:51 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry by staff. LPA met with Administrator Peter Schenkelberg and explained the reason for the visit. LPA and Administrator toured the facility. Facility is a two story house with 8 bedrooms and 7 bathrooms, a living room, dining room, kitchen and a 2 car garage. The second floor is off limits to the residents and is kept secured. The 2 car garage is used for storage and is off limits to residents. LPA observed the See Something, Say Something poster (PUB 475) in the living room. LPA observed the fireplace is screened. LPA reviewed the daily temperature log for the residents. LPA observed Covid-19 precautionary signs throughout the facility. LPA observed all the resident rooms had the required furnishings. Smoke detectors tested operational. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. Medication is kept secured in a pantry. Knives are kept locked in a kitchen cabinet. LPA observed the bathrooms are clean and operational. LPA and the Administrator toured the backyard. The exit gate is operational. No bodies of water observed. There is a seating area for residents outside. LPA observed no obstacles or hazards in the backyard. Facility has a mitigation plan that has been approved. LPA consulted with the Administrator concerning continued Covid-19 mitigation procedures and reporting requirements. No deficiencies observed. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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