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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005625
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:49:49 PM


Document Has Been Signed on 08/04/2022 01:49 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:HILL MANOR ELDERLY CAREFACILITY NUMBER:
306005625
ADMINISTRATOR:MIRABUENO, MARIA PRICILLAFACILITY TYPE:
740
ADDRESS:13021 HEWES AVENUETELEPHONE:
(714) 516-9116
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Renato Arcinas Chavez, Maria Prisicilla MirabuenoTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Rentato Arcinas Chavez and stated the purpose of this visit. Administrator Maria “Pricilla” Mirabueno arrived during the inspection to provided assistance.

The facility is a single level structure and licensed for six non-ambulatory with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Dementia.

At about 10:15 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and 2 staff members on duty. LPA reviewed the facility Personnel Report and notice Rentato Arcinas Chavez not associated. Administrator provided proof of association on 08/04/2022. Administrator also provided copies of LIC9182 and LIC 508 for Gerald Paulo Chavez. LPA informed Administrator to associated individual immediately. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms of which 1 was a shared room, 2 were a private rooms and 1 was a vacant room. There was a private staff room and restroom. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 105.2 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed mounted. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Garage is kept locked and used for storage. LPA did observe another staff member in the garage.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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 4


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: HILL MANOR ELDERLY CARE
FACILITY NUMBER: 306005625
VISIT DATE: 08/04/2022
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Kitchen was in good repair with sharp items kept locked. LPA did notice medication in the refrigerator. Administrator immediately locked medication away. LPA did inform Administrator of citation. Next to the kitchen was an operational washer and dryer. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster Plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult 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.

For this visit, One deficiency was noted in areas observed. One citation was issued. One advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Maria Pricilla Mirabueno and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/04/2022 01:49 PM - It Cannot Be Edited

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: HILL MANOR ELDERLY CARE
FACILITY NUMBER: 306005625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2022
Section Cited

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The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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