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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604595
Report Date: 07/25/2024
Date Signed: 07/25/2024 05:02:23 PM

Document Has Been Signed on 07/25/2024 05:02 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:HILLTOP HOME CARE CENTERFACILITY NUMBER:
374604595
ADMINISTRATOR/
DIRECTOR:		ANTONIO, JANE ARLYN H.FACILITY TYPE:
735
ADDRESS:110 ORANGE DRIVETELEPHONE:
(619) 777-3746
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 3DATE:
07/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Administrator Jane AntonioTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Jane Antonio.

Interviews of outside sources and facility staff widely corroborated that on 06-17-2024, Client #1 (C1) sustained multiple fresh scratches on their face. The scratches were not bleeding and did not require medical attention, but they were reddened, visible, and significant enough to require both internal and external investigation.

Records review, corroborated by manager interview, showed: Licensee initially did not report C1’s 06-17-2024 incident to CCLD. Rather, the Department learned about the incident from a concerned third-party well after seven (7) days had passed.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Antonio, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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 2
Document Has Been Signed on 07/25/2024 05:02 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/25/2024 at 04:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HILLTOP HOME CARE CENTER
FACILITY NUMBER: 374604595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2024
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements: “(b) Upon the occurrence…of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report…shall be submitted to the licensing agency within seven days following the occurrence…(1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.”
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Per manager interview, during late June 2024, facility direct care staff received training on Mandated Reporting requirements. Licensee agreed to contact a third party (such as the Long-Term Care Ombudsman’s office) to coordinate training for all facility managers on Regulation 80061 “Reporting Requirements.” Licensee agreed to E-mail copies of the training sign-in sheets for the above two topics to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records review and manager interview, Licensee did not report to the licensing agency within seven days an incident which threatened the physical health or safety of 1 of 6 clients (C1). This posed a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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