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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004760
Report Date: 09/22/2023
Date Signed: 09/22/2023 03:12:03 PM

Document Has Been Signed on 09/22/2023 03:12 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:HILDA COURTFACILITY NUMBER:
306004760
ADMINISTRATOR:DANTE D. BENEDICTOFACILITY TYPE:
735
ADDRESS:517 S. HILDA COURTTELEPHONE:
(714) 215-4337
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 3DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Marlinda Acosta
Dante Benedicto		TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Marlinda Acosta. LPA discussed the purpose of the inspection and Administrator (AD) Dante Benedicto was contacted by phone and arrived at 1:09 p.m.

During the inspection LPA and Staff Acosta conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with four client bedrooms, four bathrooms, and one staff bedroom. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two staff and three clients present. During the tour of the facility, Client 1 (C1) informed staff they were going for a walk and staff granted permission. Upon record review of C1’s Physician Repot (LIC602), C1 is not able to leave the facility unassisted and “requires supervision when outside of facility”; a Deficiency was cited on today’s date.

Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.4-107.2 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in the kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed three client files and three staff files. All three facility clients and both staff present were interviewed.

(Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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Document Has Been Signed on 09/22/2023 03:12 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/22/2023 at 02:36 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: HILDA COURT
FACILITY NUMBER: 306004760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's need.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as C1's LIC602 states C1 is not to leave the facility unassisted but was granted permission by staff to leave facility unassisted, which poses an immediate safety risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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C1 returned to facility immediately. AD stated they would conduct an in-service with staff regarding incident and following LIC602. AD will provide LPA with proof of POC via email by POC 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:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


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: HILDA COURT
FACILITY NUMBER: 306004760
VISIT DATE: 09/22/2023
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Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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