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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408520
Report Date: 10/27/2021
Date Signed: 10/27/2021 10:35:49 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:HOLY HILL HOME CARE EASTFACILITY NUMBER:
366408520
ADMINISTRATOR:LIVIUS PURACIFACILITY TYPE:
740
ADDRESS:34034 NEBRASKA LNTELEPHONE:
(909) 446-1148
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:6CENSUS: 3DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nick PuraciTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by Caregiver Marionara Cosa and LPA Brown explained the purpose of today's visit. Caregiver Cosa accompanied LPA Brown on a tour of the inside and outside of the facility. Administrator Nick Puraci arrived during the inspection.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited.
An exit interview was conducted, and a copy of this report was provided to Administrator Nick Puraci.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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