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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604029
Report Date: 08/03/2022
Date Signed: 08/03/2022 05:21:30 PM


Document Has Been Signed on 08/03/2022 05:21 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:HILLSIDE HAVEN GUEST HOMEFACILITY NUMBER:
374604029
ADMINISTRATOR:JARDIN, LEONAFACILITY TYPE:
740
ADDRESS:9141 SPICE STREETTELEPHONE:
(619) 741-3473
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:6CENSUS: 5DATE:
08/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee Leona Jardin and Caregiver Peter ChuaTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on a incident report, received by Community Care Licensing on 7/26/22. LPA was greeted and granted entry into the facility by Caregiver Peter Chua. Leona Jardin, Administrator arrived at the facility shortly after LPA's arrival and the purpose of the visit was discussed.

The facility self reported an incident regarding Resident 1 (R1) that occurred on 7/21/22. R1 reported to Licensee that Staff 1 (S1) and Staff 2 (S2) are being aggressive and abusive when assisting Resident 2 (R2). Licensee notified the responsible party for R2 and all appropriate agencies.

During today's visit, LPA toured the facility, completed a health and safety check of residents, reviewed records, and interviewed staff and residents. No deficiencies were issued during today's visit.

An exit interview was conducted with Leona Jardin, Administrator, to whom a copy of this report, LIC 811 Confidential Names and the Licensee/Appeal Rights (LIC9058 01/16) were provided to the Administrator.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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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