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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003407
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:34:02 PM

Document Has Been Signed on 05/17/2022 04:34 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILTON ARFFACILITY NUMBER:
306003407
ADMINISTRATOR:WILFREDO QUESADAFACILITY TYPE:
735
ADDRESS:12541 HILTON STREETTELEPHONE:
(714) 971-4764
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 5CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Wilfredo QuesadaTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the annual (mitigation) inspection in this facility. LPA was greeted and granted entry by Administrator (Admin) Wilfredo Quesada after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and began the tour of the facility with the Administrator.

This facility is a two level structure and licensed for three ambulatory and two non-ambulatory Developmentally Disabled clients. The facility offers a Level 4c service. As of today, LPA observed 2 clients watching television and 2 clients resting in their respective bedrooms. All clients looked happy and well taken care of.

At 3:15 pm, LPA toured the interior and exterior portions of the facility. LPA observed the required department postings at the front door and all around the facility except for the hand washing signs which were not observed in all three restrooms. LPA observed all restrooms were provided with grab bars and had ample soap/sanitizer and paper towels. Clients' bedrooms appeared clean and sanitary and had all required components. Smoke detectors, carbon monoxide, and auditory exit alarms were tested operational. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Sharp items, medications, and cleaning supplies were inaccessible to the clients in care. For the exterior portion, facility had patio furniture under ample shading. LPA observed the pool was gated and locked. LPA observed that the facility does screen and check the temperature of the clients but has discontinued. LPA reminded Admin to continue logging temperatures daily. LPA observed the emergency disaster and evacuation plans. Facility does have back-up emergency food and water supply expiring on 11/2022 and has a 30 day supply of PPEs. The First Aid Kit met all the required components.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILTON ARF
FACILITY NUMBER: 306003407
VISIT DATE: 05/17/2022
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 LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA observed a laptop and iPad was provided for the clients.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the correction. An exit interview was conducted with Administrator Wilfredo Quesada, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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