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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881050
Report Date: 03/26/2021
Date Signed: 03/26/2021 01:19:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILLSIDE SENIOR LIVINGFACILITY NUMBER:
331881050
ADMINISTRATOR:NGUYEN, JENNIFERFACILITY TYPE:
740
ADDRESS:4162 ISABELLA CIRCLETELEPHONE:
(951) 463-7588
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:6CENSUS: 0DATE:
03/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Licensee Jennifer Ngyuen and Michael McCrimmonTIME COMPLETED:
12:00 PM
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On 3/26/21 Licensing Program Analyst (LPA) Javina George conducted an announced visit for the purpose of conducting a pre-licensing inspection.
Upon arrival LPA met with Licensee/Administrator Jennifer Ngyuen and Michael McCrimmon whom assisted with the inspection. The facility is a single story house with (4) resident bedrooms (2 private and 2 shared), 2 bathrooms, dining area with a designated workspace for staff and 2 locked file cabinets for resident and staff files. The facility has a living room, backyard, and garage.

On 12/21/2020, the Lake Elsinore Office of the Fire Marshal, approved the facility for 5 Non ambulatory residents, and 1 bedridden resident.

During today's inspection, LPA toured the interior and exterior of the facility. The medications will be centrally stored and locked in a cabinet located inside of the kitchen next to the refrigerator. The smoke and carbon monoxide detectors are operable. LPA observed 1 fully charged fire extinguisher inside the kitchen. There are no fire arms or ammunition stored at the facility.

All cleaning supplies are locked inside the laundry room/pantry located inside of the kitchen. The sharp objects are stored inside the kitchen in a cabinet next to the kitchen sink. All doors, and passageways are free and clear from obstruction. The passage ways are equipped with night lights. All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items stored inside the closets located in both bathrooms. There was appropriate lighting in each room.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HILLSIDE SENIOR LIVING
FACILITY NUMBER: 331881050
VISIT DATE: 03/26/2021
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The hot water was tested and ranged from 111.9-112 degrees F. The bathrooms are equipped with grab bars and non-skid floor mats and/or surfaces. All garbage cans have tight fitting lids.

The facility is stocked with a 2 day supply of perishables and a 7 day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity. LPA observed the emergency disaster plan, facility sketch, personal rights, and theft and loss policy, PUB 475 complaint poster that will be hung on the wall/cork board inside the entryway.

There was adequate seating in the common areas. There is 1 stocked first aid kit with 1 manual. The facility is stocked with activities to provide entertainment and encourage socialization. The activities consists of: crossword puzzles, adult coloring books, board games, playing cards, light workout equipment and opportunities for low maintenance gardening.

An exit interview was conducted and a copy report was provided to Licensee/Administrator Jennifer Ngyuen and Michael McCrimmon.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC809 (FAS) - (06/04)
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