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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604045
Report Date: 07/29/2024
Date Signed: 07/29/2024 03:26:35 PM


Document Has Been Signed on 07/29/2024 03:26 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 VIFACILITY NUMBER:
374604045
ADMINISTRATOR:LOFVENDAHL, BRIGITTA MFACILITY TYPE:
740
ADDRESS:662 TRANQUILITY GLENTELEPHONE:
(760) 743-8843
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:15CENSUS: 15DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Executive Director,Brigitta LofvendahlTIME COMPLETED:
01:50 PM
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On today's date 07/29/24 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. 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 (1) resident receiving hospice services.

The facility is a single story structure with 8 combined bedrooms and bathrooms, dining area, front and back patio, kitchen, living room, medication closet, and garage which is used to store the laundry appliances, generator and extra food. The facility was observed to be clean and clutter and odor free. The call lights were tested and observed to be operable. LPA observed all toxic chemicals and other hazards/sharps to be inaccessible to residents. The medications are locked inside the mediation closet, that is accessed via a key pad. The facility food supply met the requirements of a 2 day supply of perishable and a 7 day supply of non perishable food items. There are no pools or bodies of water on the premises, are known guns or ammunition. LPA tested the pull cord/signal system and observed for bedroom#5 pull cord to be inoperable, the cord was replaced during LPAs visit, therefore no citation was issued.
LPA conducted a records review and observed the following: 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 possess a valid Administrator certificate which expires on 04/16/2025. Resident files were observed to have the required documentation such as physician's report, appraisal, and admissions agreement.
The hot water temperature was tested and found to be within regulatory limits. The facility was observed to have (3) fully charged fire extinguishers fully charged. The emergency drills are conducted quarterly, the last drill was conducted on 4/16/24. LPA conducted a file review prior to inspection and observed for there to be outstanding annual fees, during today's visit, proof was provided confirming that the fees have been paid. Based on today's inspection no deficiencies were issued.
An exit interview was conducted and a copy of this report was provided Executive Director,Brigitta Lofvendahl.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
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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