<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410195
Report Date: 04/28/2022
Date Signed: 04/28/2022 05:02:34 PM


Document Has Been Signed on 04/28/2022 05:02 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
RIVERSIDE, CA 92507



FACILITY NAME:HILLS OF ALCOBA, THEFACILITY NUMBER:
336410195
ADMINISTRATOR:ESTRELLA SAVARFACILITY TYPE:
740
ADDRESS:43707 ALCOBA DRIVETELEPHONE:
(951) 694-6779
CITY:TEMECULA,STATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 5DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Staff- Barry TIME COMPLETED:
05:15 PM
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), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Administrator Sylvia Busby, who was informed of the purpose of the visit. At the time of the visit there were 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented.

LPA observed several deficiencies during the visit. Due to this, a virtual meeting will be scheduled for next week where Administrator Sylvia Busby will meet with LPA and LPA's Manager.

The intimidate deficiencies that will be cited today will be:
ยท LPA observed 2 staff members, S1 and S2 at the facility. S1 is not currently associated to the facility. S2 has been associated to the facility 4/25/2022 however LPA observed S2's initials on MARS log for the entire month. Immediate civil penalties will be given in accordance to Title 22 Section 80019(e)(2) in the amount of $1000.

An exit interview was conducted, and a copy of this report and appeal rights were given to facility Administrator Sylvia Busby.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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 2


Document Has Been Signed on 04/28/2022 05:02 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: HILLS OF ALCOBA, THE
FACILITY NUMBER: 336410195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above with staff member (S1) who was not associated to the facility and was alone with all residents at the beginning of the visit. This poses an immediate safety risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
1
2
3
4
 Administrator is to read regulation and submit e-mail statement to LPA by POC date.
Type A
Section Cited
CCR
80019(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above with staff member (S2), who was not associated to the facility. S2 was not associated to the facility until the end of the month 4/25/2022, but was working there since the 4/1/2022. This poses an immediate safety risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
1
2
3
4
Licensee will associate staff member to facility by POC date. Licensee will read regulation and submit proof to LPA through e-mail.

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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2