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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003407
Report Date: 05/10/2023
Date Signed: 05/11/2023 07:17:49 AM

Document Has Been Signed on 05/11/2023 07:17 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: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:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Wilfredo QuesadaTIME COMPLETED:
03:45 PM
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On 04/13/2023, Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year Annual inspection. LPA Martinez rang Ring door bell and knocked on the door several times. Received no answer. LPA to return at a later date to complete Required - 1 Year Annual visit.
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On 05/10/2023, LPA Martinez made an unannounced visit and was greeted and granted entrance into the facility by Administrator Wilfredo Quesada and reason for visit was explained. There are currently 4 Clients residing at the facility. All Clients and two staff were present. LPA Martinez, along with Staff Quesada conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following: Facility is a two story house with 5 bedrooms, 3 bathrooms, living room, kitchen, dining room and an attached two care garage that is used for storage. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. The back yard has a patio cover with a table and 6 chairs for clients and visitors. Backyard pool was observed to be fenced and secured. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Hot water temperature in client bathroom was within regulatory requirements. Linen and hygiene supplies were stocked in hallway closet. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Emergency food and water supply is available. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguisher were charged and mounted. Fire drills are conducted once a month and LPA verified last Fire Drill was conducted on 04/13/23. Stove burners, microwave, dishwasher, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Medications are centrally stored in a locked cabinet upstairs. Medications reviewed appear to have been dispensed accurately.
(see LIC809C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILTON ARF
FACILITY NUMBER: 306003407
VISIT DATE: 05/10/2023
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First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan is posted.

LPA reviewed four client files and one staff file. LPA interviewed 2 of 4 clients and staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 05/25/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.



Based on observations made during today's visit in the areas reviewed, no deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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