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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406352
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:03:40 PM

Document Has Been Signed on 04/28/2023 03:03 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: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: 3DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator Evelyn GreenTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with Administrator Evelyn Green. At the time of the visit, two(2) clients were present at the facility.
LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/16/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the laundry areas. Centrally stored medications were kept in a safe and locked cabinet. LPA measured the hot water temperature in the bathrooms and kitchen. The hot water temperature in the client bathroom was within required limits. LPA observed emergency supplies in the garage. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water.
LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. LPA observed the signs and postings in a common area. LPA observed the Emergency Disaster Plan was not updated as of 2021. LPA did not see the visitation policy posted. Deficiencies were issued. Sufficient staff are employed and present in the facility to meet the needs of the clients in care.
Two (2) deficiencies were issued during this visit. An exit interview was conducted where this report, LIC 809, LIC809-D and appeal rights was provided to the Administrator Evelyn Green, at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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Document Has Been Signed on 04/28/2023 03:03 PM - It Cannot Be Edited


Created By: Victoria Chitgian On 04/28/2023 at 02:37 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: OAK HILL HOME
FACILITY NUMBER: 366406352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(e)
(e)The information specified … including the visiting policy as stated in the admissions agreement shall be prominently posted in areas accessible to clients and their visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the Visitation Policy is not posted in a common and visible area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Administrator shall post the facility visitation policy in a common area and submit proof to LPA via email by POC due date above.
Type B
Section Cited
HSC
1565(d)
The facility shall review the emergency and disaster plan annually and make updates as necessary...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited aboveas the emergency and disaster plan LIC 610D was not updated as of 2021, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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Administrator shall provide an updated LIC 610D and submit proof to LPA by POC date above.
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:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
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