371881361-8-29-2022-18-AS-YDEO-CHRSG5-20220829135122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881361
Report Date: 08/29/2022
Date Signed: 08/29/2022 01:51:34 PM

Document Has Been Signed on 08/29/2022 01:51 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
RIVERSIDE, CA 92507

FACILITY NAME:	QUIET HILLS LIVING		FACILITY NUMBER:	371881361
ADMINISTRATOR:	BLAKE, MARY ANN		FACILITY TYPE:	740
ADDRESS:	884 GRETNA GREEN WAY		TELEPHONE:	(760) 270-2075
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	May Ann Blake, Administrator		TIME COMPLETED:	02:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:10 AM, LPA met with Administrator May Ann Blake. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 6/1/2022 for a total capacity of six (6) non-ambulatory and zero (0) bedridden residents. Fire clearance was granted on 8/18/2022. LPA Delgado observed the following: Structure: Facility was a two-story house with four (4) resident bedrooms, Bedroom #5 for one (1) ambulatory resident, Bedroom #6 upstairs not for residents use. Four (4) resident bathrooms and one (1) staff bathroom, living room, dining area and kitchen. There was an attached two car carport in the front of the house. There is a chair lift in the hallway leading up to the second floor. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the living room to control first floor and there is another central panel located on the second floor in Bedroom #5. Bedrooms: Each resident bedroom #1, #2, #3 and #4 will accommodate any non-ambulatory resident, bedroom #5 will accommodate ambulatory resident. 5 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The 4 resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 11:11 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured between 86-105 degrees Fahrenheit. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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
RIVERSIDE, CA 92507

FACILITY NAME: QUIET HILLS LIVING	FACILITY NUMBER: 371881361
	VISIT DATE: 08/29/2022

NARRATIVE

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(CONTINUED FROM LIC 809)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the home. Laundry detergents and cleaning supplies were observed in a closet inside the hallway away from residents.
Living/Family room:
There was a living room with TV and seating for all clients, there is family room with TV and seating for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a closet in the hallway of the residence.
Yards/Outside:
Patio table and six chairs were observed in the backyard; more shade is needed. There was two gates on the South side of the property with a self-latching exterior doors. All outdoor pathways were free of obstructions. There is an in-ground pool with a black fencing around it that was observed and it is not on the Emergency Disaster Plan sketch.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the kitchen, living area and second floor by the fire extinguisher. Obudsman poster and Let-Us-No poster observed.
General items:
Three (3) fire extinguishers were charged and located in the kitchen, laundry room and in hallway on the second floor. Eleven (11) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order except for one (1) upstairs next to the Staff room. Client and Staff records will be stored in a locked desk in the Living room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was not sufficient however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was completed on this day as well.

(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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
RIVERSIDE, CA 92507

FACILITY NAME: QUIET HILLS LIVING	FACILITY NUMBER: 371881361
	VISIT DATE: 08/29/2022

NARRATIVE

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(CONTINUED FROM LIC 809)

Pre-Licensing is incomplete and the following corrections to be resolved by 8/31/2022:

obtain a separate 72-hour emergency food supply
obtain additional emergency water
obtain a licensed plumber to adjust and verify water temperature between 105-120 degrees Fahrenheit for all sink and showers.
updated facility sketch to include pool area and exit gates
repair smoke detector on the second floor next to Staff room
Remove in-operable lamp from bedroom #2
Remove beds in Staff room
Obtain a lock for Staff room door
Obtain night lights for hallways and passages to restrooms
Obtain a "No Smoking-Oxygen in Use" sign
Obtain Emergency supplies
obtain shade for outdoor patio table

An exit interview was conducted, and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC809 (FAS) - (06/04)

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