374603381-9-6-2023-18-AS-CGOH-CVEQ2M-20230906114722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603381
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:49:34 AM

Document Has Been Signed on 09/06/2023 11:49 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	HUMMINGBIRD HILL		FACILITY NUMBER:	374603381
ADMINISTRATOR:	CHRIS B. CONKLIN		FACILITY TYPE:	740
ADDRESS:	1027 CALLE DE LIMAR		TELEPHONE:	(760) 723-9414
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	5	CENSUS: 0	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Chris Conklin, Administrator		TIME COMPLETED:	11:47 AM

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	On 09/06/23 at 10:22 a.m. Licensing Program Analyst (LPA) Cheryl Goodrich arrived to conduct an unannounced annual visit. LPA met with Administrator Chris Conklin and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. The facility is approved for five (5) residents, with 0 residents in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility has 2 bedrooms, and 2 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with night stand, lamp, and closet space. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The living room and kitchen clean and clear of obstruction. The medications are stored in a lockbox in the kitchen and inaccessible to residents. The RCE and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HUMMINGBIRD HILL	FACILITY NUMBER: 374603381
	VISIT DATE: 09/06/2023

NARRATIVE

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(Continued from LIC809)

Personnel Records-Training: There are currently no staff working at the facility due to no residents in care other than the Administrator. The previous staff records were completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings.
Client Records-Incident Reports: There are no residents in care currently and there have been no residents since 2019. The previous resident records were complete with pre-assessments, identification and emergency contacts, admission agreements, doctor’s orders, and additional assessments.
Client Rights-Information: The resident rights information present and on file available for staff and residents.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health-Related Services: There is no dispensing of medication due to no residents in care, however medication lock box is present with facility medication logbook.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator Chris Conklin and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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