<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604043
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:28:55 PM


Document Has Been Signed on 07/02/2024 03:28 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:HIDDEN GLENN SENIOR LIVING IVFACILITY NUMBER:
374604043
ADMINISTRATOR:LOFVENDAHL, BRIGITTA MFACILITY TYPE:
740
ADDRESS:642 TRANQUILITY GLENTELEPHONE:
(760) 743-8843
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:15CENSUS: 13DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Brigiitta Lofvendahl, Administrator TIME COMPLETED:
01:15 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
On today's date 07/02/24 at 11:47am Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA met with Executive Director Brigitta Lofvendahl and explained the purpose of the visit. At the time of the inspection there were 3 staff and 13 residents present. The facility is licensed to serve residents age 60 and over, 15 non ambulatory of which 15 may be bedridden. The facility has an approved hospice waiver for six (6). There is currently one (1) resident receiving hospice services. Below are the observations made during today's visit:

The facility is a single story structure with 7 combined bedrooms and bathrooms, dining area, front and back patio, kitchen, living room and medication room. The facility was observed to be clean and clutter and odor free. The resident bedrooms were observed to have the required furniture, the call lights were observed to be operable.The facility food supply was sufficient. LPA observed all toxic chemicals and other hazards/sharps to be inaccessible to residents.

The hot water temperature was tested and found to be within regulatory limits. The facility has fire extinguishers fully charged with the tags in tact. The emergency drills are conducted quarterly, the last drill was conducted on 4/16/24. The last fire inspection was conducted on 12/14/23.

Records review: Staff present were observed to have obtained criminal record clearance and to be associated to the facility. Staff present were observed to have current CPR/First Aid training, and the Administrator certificate which expires on 04/16/2025. Resident files had the required documentation such as physician's report, appraisal, and admissions agreement.

No deficiencies were observed during today's annual inspection.
An exit interview was conducted and a copy of the report and LIC 811 was provided to the Executive Director,Brigitta Lofvendahl .
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1