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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003407
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:13:05 PM

Document Has Been Signed on 07/24/2024 03:13 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/
DIRECTOR:		WILFREDO QUESADAFACILITY TYPE:
735
ADDRESS:12541 HILTON STREETTELEPHONE:
(714) 971-4764
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 5CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Wilfredo QuesadaTIME VISIT/
INSPECTION COMPLETED:
03:27 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Samer Haddadin for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Wilfredo Quesada and discussed the purpose of the inspection.

LPAs reviewed Infection Control requirements. At about 12:45PM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 3-bathroom, two-story house with attached garage that is used for storage. There is a back yard with a patio cover for the clients and a pool with a gate that meets title 22 regulations. LPAs observed 2 staff and 4 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPAs inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 106.8 degrees F in the 2 client bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the garage. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:30PM, LPAs reviewed 4 client files and 3 staff files, interviewed 4 clients and 1 staff, inspected medications for 4 clients, and inspected client money and ledgers for 4 clients.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 07/24/2024 03:13 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/24/2024 at 02:52 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILTON ARF
FACILITY NUMBER: 306003407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the administrator has not completed HIV/TB training in the last 2 years, which poses a potential health risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee stated they will complete the 3 hour HIV and 1 hour TB training and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 4 clients, which poses a potential personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee stated they will execute their own approved admission agreements with all 4 clients and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/24/2024 03:13 PM - It Cannot Be Edited


Created By: Sean Haddad On 07/24/2024 at 02:52 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILTON ARF
FACILITY NUMBER: 306003407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the facility does not have an up to date 9-page LIC610D, which poses a potential safety risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee stated they will create a 9-page LIC610D and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 07/24/2024
NARRATIVE
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During the inspection, LPAs and AD observed the following: based on documents, the administrator has not completed HIV/TB training in the last 2 years; based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 4 clients; and based on documents, the facility does not have an up to date 9-page LIC610D.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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