366408520-10-14-2022-56-AS-BALN-CK7N4A-20221014100737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408520
Report Date: 10/14/2022
Date Signed: 10/14/2022 10:07:52 AM

Document Has Been Signed on 10/14/2022 10:07 AM - 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:	HOLY HILL HOME CARE EAST		FACILITY NUMBER:	366408520
ADMINISTRATOR:	LIVIUS PURACI		FACILITY TYPE:	740
ADDRESS:	34034 NEBRASKA LN		TELEPHONE:	(909) 446-1148
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	6	CENSUS: 4	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Puraci Livius Administrator		TIME COMPLETED:	10:20 AM

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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Bernadette Allen identified herself to Administrator, Puraci Livius who was informed of the purpose of the visit.

During the inspection, Puraci Livius email LPA a copy of the LIC808 infection control which included addendum for monkey pox. Puraci Livius confirmed that there are currently no Covid-19 cases at the facility.

LPA, Allen observed appropriate postings in the facility, including personal rights and visitation policies, which were in accordance with the Department's guidelines. LPA, Allen observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 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 and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. 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 emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA, Allen observed that the facility appeared to be meeting operational requirements. LPA, Allen

observed that all utilities and appliances were functioning properly, and all passageways were clear of obstruction, including emergency exits. The facility was equipped with sufficient food supply including a 7-day of non-perishables and 2-day of perishables and emergency supplies.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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: HOLY HILL HOME CARE EAST	FACILITY NUMBER: 366408520
	VISIT DATE: 10/14/2022

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All inspected areas of the facility appeared clean and in good repair. LPA Allen observed no apparent health and safety risks at the time of visit.

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed, and a copy was provided to Puraci Livius at the conclusion of the inspection.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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