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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604370
Report Date: 09/16/2024
Date Signed: 09/16/2024 03:37:22 PM

Document Has Been Signed on 09/16/2024 03:37 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:KELLY'S OAKHILL VILLAFACILITY NUMBER:
374604370
ADMINISTRATOR/
DIRECTOR:		MARYLINE SIADTOFACILITY TYPE:
740
ADDRESS:1620 OAKHILL DRIVETELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 6DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Maryline Siadto, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 09/16/24 at 1:17pm Licensing Program Analysts (LPAs) Debbie Palacios and Javina George, made an unannounced visit to the facility to conduct a 1 year required visit LPAs were greeted and granted entry by Administrator Maryline Siadto, where LPAs explained the purpose of the visit. At the time of the visit there was (2) staff and (60 residents present. The facility currently has (4) residents receiving hospice services with an approved waiver for 6. In addition there is (1) resident receiving home health services.

LPAs conducted a tour of the interior and exterior of the interior and exterior areas of the facility.
The facility is a nine (9) bedroom, four (4) bathroom single story home with a shed in the backyard that is being used for storage. LPAs observed for the facility to be utilizing Video surveillance in two resident bedroom Resident # 2 (R2) and Resident #3 (R3). Both residents have consents on file. LPAs also observed for R2 to have a keypad lock on their door, however LPAs confirmed that R2 was able to operate the door, R2 was observed walking throughout the facility and did not observe any latches that would lock R2 inside their bedroom.

The facility is conducting emergency disaster drill, the last drill was conducted on a quarterly basis and the last drill was conducted on 08/12/24. The facility has (2) fully charged fire extinguishers. The hot water was tested and measured between 114.7-117 degrees Fahrenheit, which is within regulatory limits. The facility food supply was adequate, LPAs observed for there to be (2) packages of expired food. There was no citation issued due to the items being discarded during LPAs visit.

The resident and staff files had the appropriate forms. All staff present were observed to have obtained criminal record clearance, and to be associated to the facility. The facility Administrator Maryline Siadto was observed to have a valid administrator's certification which expires 10/24/24. There were no citations issued during today/s inspection. An exit interview was conducted and a copy of this report was provided to Maryline Siadto, Administrator.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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