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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004760
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:26:39 PM

Document Has Been Signed on 09/11/2024 04:26 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILDA COURTFACILITY NUMBER:
306004760
ADMINISTRATOR/
DIRECTOR:		DANTE D. BENEDICTOFACILITY TYPE:
735
ADDRESS:517 S. HILDA COURTTELEPHONE:
(714) 215-4337
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 3DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Kathleen ChengTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit for the purpose of conducting a Required - 1 Year inspection. LPA was greeted and granted entry by Direct Support Professionals (DSP's) Kathleen Cheng and Gloria Soriano and LPA discussed the purpose of the visit. Administrator (AD) Dante Benedicto was contacted by phone but was not available to join LPA. LPA and DSP's conducted a tour of the inside and outside of facility, common areas, client rooms, kitchen, garage and observed the following: LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. The back yard has a shaded sitting area. LPA observed two staff and three clients present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Hot water temperature was within regulatory requirements. 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. 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 and mounted. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed in a centrally stored location inaccessible to the clients and medication reviewed appeared to have been dispensed accurately. LPA reviewed three client files and two staff files. All three facility clients and both staff present were interviewed. P & I money was not available for review. No documentation of Fire Drills being conducted was available for review. As of today, the Annual Licensing fees are due. As a reminder, LPA provided staff with a copy of the most recent billing for annual fees due to be paid.

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 these reports, along with Appeals Rights was sent to email on file.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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 09/11/2024 04:26 PM - It Cannot Be Edited


Created By: Lydia Martinez On 09/11/2024 at 03:39 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, there is no documentation that fire drills are being conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Licensee to conduct Emergency Disaster drills and document, proof to be sent to LPA by POC due date.
Type B
Section Cited
CCR
80026(j)
(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in that P&I was not available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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P&I / Cash resources entrusted to the licensee should be kept on facility premises and shall be available for review at anytime and available for client if needed. LPA to conduct visit at a later date to review P&I.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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