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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530050
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:22:08 PM


Document Has Been Signed on 11/16/2023 12:22 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:HILLSIDE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
365530050
ADMINISTRATOR:RICHARDSON, STEPHANIEFACILITY TYPE:
740
ADDRESS:15027 MANNING STREETTELEPHONE:
(818) 259-9107
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY:6CENSUS: 3DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Stephanie Richardson- LicenseeTIME COMPLETED:
12:32 PM
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On 11/16/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee, Stephanie Richardson and introduced self and stated purpose of the visit. LPA was informed that there are currently 3 residents in care.

The facility has 3 bedrooms, 2.5 bathrooms, kitchen, dining area, living room, office, laundry, attached garage and backyard with 2 sheds. LPA completed a walk through of facility, review of records and medication audit.

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 of 71 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 124.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, CCL complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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: HILLSIDE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 365530050
VISIT DATE: 11/16/2023
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard, two sheds used for storage and one inaccessible jacuzzi.

Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed an incomplete physician's report for one resident. Technical violation issued.

One technical violation was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to Licensee, Stephanie Richardson.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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