336409085-9-29-2023-18-AS-SMAZ-CW5NWN-20230929104950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409085
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:50:18 AM

Document Has Been Signed on 09/29/2023 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	HILLTOP GUEST HOME		FACILITY NUMBER:	336409085
ADMINISTRATOR:	MARISSA MASHBURN		FACILITY TYPE:	740
ADDRESS:	30951 BLACKHORSE DRIVE		TELEPHONE:	(951) 244-6837
CITY:	CANYON LAKE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS: 4	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Christopher Bundalian - Administrator		TIME COMPLETED:	11:06 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Christopher Bundalian, who was informed of the purpose of the visit. At the time of the visit there was three (3) staff and one (1) client present.

The facility is a one story home with (6) bedrooms and (3) bathrooms with an attached garage, and a backyard. The facility does not contain any bodies of water, firearms, or ammunition on the property. The clients served are elderly adults 65 years of age and older. Clients are vendorized by Inland Regional Center (IRC). LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. PPE equipment and cleaning supplies were available to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and staff training which met department requirements.

Physical Plant: LPA observed the client bedrooms, bathrooms, and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were present and were in good repair. The outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 116.4 F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HILLTOP GUEST HOME	FACILITY NUMBER: 336409085
	VISIT DATE: 09/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway closet. LPA reviewed medications for three (3) clients and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drill was conducted on 08/03/2023 which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and entry way closet and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Christopher Bundalian.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2