361800216-12-4-2023-56-AS-MRIO-CY86G4-20231204194720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800216
Report Date: 12/04/2023
Date Signed: 12/04/2023 07:47:30 PM

Document Has Been Signed on 12/04/2023 07:47 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:	HILEA HOME		FACILITY NUMBER:	361800216
ADMINISTRATOR:	MORENO, DARLENE		FACILITY TYPE:	735
ADDRESS:	14032 OLEMA RD		TELEPHONE:	(760) 503-0124
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY: 4		CENSUS: 4	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	05:33 PM
MET WITH:	Silvia Rodriguez and Darlene Moreno		TIME COMPLETED:	08:00 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) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Silvia Rodriguez and was granted entry to the facility. The facility is a (4) bedroom (3) bathroom home and, with a kitchen/dining area, living room, attach garage. The facility is an Adult Residential Facility (ARF) level I7 designated home vendor by Inland Regional Center. Licensed capacity is (4) current census (4). LPA was accompanied by Silvia Rodriguez to conduct 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 client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (2) client medication. LPA was not able to review clients P&I.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
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)

Page: 1 of 3

Document Has Been Signed on 12/04/2023 07:47 PM - It Cannot Be Edited

Created By: Mary Rico On 12/04/2023 at 07:06 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HILEA HOME	FACILITY NUMBER: 361800216
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80070(d)

80070(d) Client Records (d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 by not having clients records P&I available for LPA ofwhich poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Licensee will send LPA proof they undertstand the regulation. Licensee will send clients records via-email and will provide staff with training to have records available for licensing agency to inspect.

Type A

Section Cited

CCR

80066(e)

80066(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review 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 by not having Personnel Records available for licensing agency to review which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Licensee will send LPA proof they understand the regulation. Licensee will send personnel records of staff via-email. Licensee will provide training to have records available for licensing agency to inspect.

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:

Efren Malagon

LICENSING EVALUATOR NAME:

Mary Rico

LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HILEA HOME	FACILITY NUMBER: 361800216
	VISIT DATE: 12/04/2023

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

During today’s visit, Administrator was not able to provide Personnel Records and Clients Records P&I. Personnel Records and Client’s P&I were not available for LPA to audit. S1 and S2 did not have access to records and Administrator was not available to come to the facility to provide records.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Jasmine Zinto. Along with the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
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)

Page: 3 of 3