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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800102
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:40:50 PM

Document Has Been Signed on 05/19/2023 02:40 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILO HOMEFACILITY NUMBER:
361800102
ADMINISTRATOR:GLAUDE, JAMESFACILITY TYPE:
735
ADDRESS:15953 KEWANEE ROADTELEPHONE:
(760) 503-9486
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 3DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:James Glaude, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Hilo Home Adult Residential unannounced to conduct the Annual Inspection. LPA knocked on the main entrance door and was greeted and granted entry by staff member, James Glaude, Administrator. LPA was requested to sign in and have temperature taken, then provided a space to work. LPA was informed the current census is 3. At time of visit, residents were preparing to leave for their prospective Day Programs. LPA conducted a general overall inspection, which included, but was not limited to, the following:

LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the temperature from the bathroom faucet, which read within regulation. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, infection control, disaster plans and licensing signage were posted in a common areas. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in the laundry room in secure cabinetry. There was a designated storage space for residents/staff files. Medications were locked and inaccessible to residents. The facility had emergency and first aid kits readily available for residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HILO HOME
FACILITY NUMBER: 361800102
VISIT DATE: 05/19/2023
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Food Service: Non-perishable and perishable food supply is sufficient for number of residents residing in the facility. Facility has a variety of food available for residentss. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.
Record Review: LPA reviewed 2 residents files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 5 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. The facility last conducted a disaster drill on 5/19/23. Last earthquake drill in April 2023. Fire Extinguisher last inspected January 2023.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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