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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603381
Report Date: 08/26/2024
Date Signed: 08/26/2024 02:29:05 PM


Document Has Been Signed on 08/26/2024 02:29 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:HUMMINGBIRD HILLFACILITY NUMBER:
374603381
ADMINISTRATOR:CHRIS B. CONKLINFACILITY TYPE:
740
ADDRESS:1027 CALLE DE LIMARTELEPHONE:
(760) 723-9414
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:5CENSUS: 0DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Christrid Conklin, AdministratorTIME COMPLETED:
02:35 PM
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On 08/26/24 at 1:00pm Licensing Program Analyst (LPA) Javina George made an unannounced annual visit to facility. LPA met with Administrator Christid Conklin and was granted entry. The facility is approved for five (5) residents, with 0 residents in care, with an approved hospice waiver for 1. Below are the observations that were made during today's inspection:

The facility is a two story structure consisting of 3 bedrooms 1 of which is for staff use, and 3 bathrooms, and an in law suite, living room, kitchen, and backyard. The bedrooms are furnished with night stand, lamp, and closet space. The living room and kitchen clean and clear of obstruction.

The smoke and carbon monoxide detectors were tested and found to operable. LPA did not observed any medications, or review records as the facility does not have any residents in care. The Administrator Christid was observed to possess a valid administrator certificate that expires on 08/28/25. The facility was observed to have a 7-day supply of non-perishable and 2 day of perishable food items was observed. The facility has fully charged fire extinguishers with the tag in tact. The facility is secured with an alarm as well as video surveillance. There are cameras installed on the interior and exterior of the facility, as well as in the ceiling inside the resident bedrooms, LPA explained that an addendum to the plan of operation, written consent, and an updated facility sketched would be needed.

Based on today's visit, no deficiencies were observed. The following is needed prior to accepting a resident: -Liability insurance is to be obtained and a copy is to be provided to the regional office.
-Staff are to obtain valid CPR/First Aid certification

An exit interview was conducted with Administrator Chris Conklin and a copy of this report was provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
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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