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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600558
Report Date: 07/29/2024
Date Signed: 07/29/2024 03:53:19 PM

Document Has Been Signed on 07/29/2024 03:53 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HIDDEN VALLEY RANCHFACILITY NUMBER:
374600558
ADMINISTRATOR/
DIRECTOR:		SMITH, GLENNFACILITY TYPE:
735
ADDRESS:535 HAVERFORD ROADTELEPHONE:
(760) 788-3490
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 12CENSUS: 10DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:32 AM
MET WITH:Director Elena O'Connor, LIfe Skill Trainer Jazmin Tabarez TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced visit for a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Life Skill Trainer Jazmin Tabarez. Due to a COVID outbreak at the facility, an inspection of the interior of the facility was not initiated. Director Elena O'Connor,joined the LPA at the facility and brought facility records from an off-site office location.

The facility has five (5) residents who tested positive to COVID-19 on Tuesday, 07/23/2024 and Thursday 07/25/2024. The residents are isolated in their rooms and are not currently experiencing headaches,body aches, or temperatures. One resident has a slight cough.


During today’s visit, LPA reviewed facility, staff, and resident records and toured the outside of the facility with Director Elena O'Connor. No deficiencies were cited during today’s visit. Due to the COVID-19 outbreak in the facility, a return visit on a subsequent day is needed to complete the annual inspection.

An exit interview was conducted with the Director Elena O'Connor, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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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