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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800216
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:56:25 AM

Document Has Been Signed on 02/23/2023 11:56 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILEA HOMEFACILITY NUMBER:
361800216
ADMINISTRATOR:MORENO, DARLENEFACILITY TYPE:
735
ADDRESS:14032 OLEMA RDTELEPHONE:
(760) 503-0124
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 2DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Adminsitrator James GlaudeTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct an annual inspection with a focus on infection control. LPA was granted entry by staff Silvia Rodriguez and met with Administrator James Glaude and explained the purpose of the visit. At the time of visit there were two (2) staff and one (1) client present. Two (2) clients were out at a Skilling Nursing Facility, and one (1) client out at day program. Currently the facility is Covid-Free.

LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. The entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. LPA observed postings for handwashing and proper cough etiquette throughout. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels). LPA observed a thirty (30) day supply of Personal Protective Equipment (PPE) which includes gloves, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer. PPE was stored in the Office.

The facility staff has a plan in place to manage Covid-19 symptoms, which includes staff monitoring clients regularly for any changes in condition and daily symptom checks. The facility will contact the client's physician in the event of any Covid-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift multiple times a day. All staff and clients are practicing all other infection control precautions, which minimize the risk of them contracting Covid-19.

LPA toured the facilities interior and exterior and there were no health and safety concerns. Based on the observations made during today’s visit, no deficiencies were issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report (LIC809) was provided to Administrator James Glaude.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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