336408194-12-4-2023-56-AS-BALN-CY7S7H-20231204123734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408194
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:37:41 PM

Document Has Been Signed on 12/04/2023 12:37 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	HILLCREST COTTAGE		FACILITY NUMBER:	336408194
ADMINISTRATOR:	NOEMI MAMANI		FACILITY TYPE:	740
ADDRESS:	1087 HILLCREST CT		TELEPHONE:	(909) 795-5748
CITY:	CALIMESA	STATE: CA	ZIP CODE:	92320
CAPACITY:	6	CENSUS: 6	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Noemi Mamani Licensee		TIME COMPLETED:	12:45 PM

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Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection. At the time of the visit there was one (1) staff member and (6) residents.LPA met with Noemi Mamani who was informed of the purpose of the visit.

LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

The Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and lighting and is maintained at a comfortable temperature.

There was enough nonperishable and perishable food for the number of residents in care.The facility has a variety of food available for residents, and a menu was available for review. The facility food is stored in a safe manner.

Sharps are stored in the locked laundry room inaccessible to clients in care.

The resident’s bedrooms are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting.

All bathrooms had non-slip mats and were operating in a safe and in good sanitary condition. The hot water temperature measured between 105-120-degrees F. LPA also observed the facility is equipped with operating carbon monoxide/smoke detectors and fully charged fire extinguishers.

Posters such as personal rights and the disaster plan were posted in a common area.

LPA did observe cleaning supplies,toxins items are kept in the locked laundry room in the kitchen area inaccessible to clients in care. The resident’s files were reviewed, all files had the required documents at the time of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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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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
, CA 92507

FACILITY NAME: HILLCREST COTTAGE	FACILITY NUMBER: 336408194
	VISIT DATE: 12/04/2023

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LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans.

LPA also reviewed two(2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

An exit interview was conducted, and this report was discussed and provided to Noemi Mamani at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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