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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406352
Report Date: 06/30/2022
Date Signed: 06/30/2022 07:36:32 PM

Document Has Been Signed on 06/30/2022 07:36 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
, CA 92507
FACILITY NAME:OAK HILL HOMEFACILITY NUMBER:
366406352
ADMINISTRATOR:EVELYN GREENFACILITY TYPE:
735
ADDRESS:2420 S. OAK HILL DRIVETELEPHONE:
(909) 218-4936
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 4DATE:
06/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Evelyn GreenTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Melody Brown made an unannounced in-person visit to the facility 06/30/2022 at 01:45 PM regrading a self-reported incident which occurred on 06/19/2022. LPA Brown gained access to the facility and identified no immediate health and safety issues.

During the visit, LPA Brown tour the facility with Staff 3 then Administrator Evelyn Green arrived and informed LPA Brown that she just received notification that a staff of the facility (Staff 4) tested positive and showed proof of Covid-19 positive result to LPA Brown. Due to the reported information, LPA Brown was unable to continur the tour of the facility and to interview clients and staff at the facility and requested Administrator Evelyn Green to continue the visit via Teams Meeting and Administrator Green agreed.

The facility reported to Community Care Licensing Division (CCLD) that Resident 1 (C1) fell that resulted in a swollen finger and C1 was assessed for possible concussion and nasal fracture at the Emergency Room. Administrator Green reported that she was aware of the incident but she was not working at the facility during the time of the incident. However, Administrator Green confirmed that the staff member in question, Staff 2 (S2) is currently on Administrative Leave pending facility investigation of the incident.

LPA Brown requested to Administrator Green to email pertinent records for review. LPA Brown conducted clients and staffs interviews via Teams Meeting. Interviews with staffs revealed that C1 has history of lying and fabricating stories. Also, interviews indicated that Client 3 (C3) witnessed the reported incident to CCLD. C3 reported witnessing the incident and said "I saw it! I was looking on my bedroom door. C1 stepped on what I believed like an underwear or a towel and C1 slip and fell. I am 100% positive that S2 did not push or hit C1."

*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: OAK HILL HOME
FACILITY NUMBER: 366406352
VISIT DATE: 06/30/2022
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An exit interview was conducted, where this report was discussed with Administrator Evelyn Green. A copy of this report was provided via email and a read receipt confirms receipt of the report. Administrator Evelyn Green has agreed to sign the report and returned the copy to LPA Brown.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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