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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604595
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:20:15 AM


Document Has Been Signed on 02/15/2024 10:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:HILLTOP HOME CARE CENTERFACILITY NUMBER:
374604595
ADMINISTRATOR:ANTONIO, JANE ARLYN H.FACILITY TYPE:
735
ADDRESS:110 ORANGE DRIVETELEPHONE:
(619) 777-3746
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:6CENSUS: 2DATE:
02/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Direct Support Professional Ruth RabinaTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Juliana Barfield and Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced case management visit due to a request to change the facility capacity and ambulatory status. LPA and LPM were greeted by, identified themselves to, and discussed the purpose of the visit with Direct Support Professional Ruth Rabina. Director Jane Arlyn Antonio later joined the visit.

A Change of Capacity and non-ambulatory application was received by the Department on 11/22/2023, in which the licensee requested a decrease in capacity and Ambulatory status from six (6) ambulatory clients to four (4) non-ambulatory clients. The Fire Safety Inspection Request was approved by the local fire authority on January 17, 2024.

During today’s visit, LPA and LPM toured the facility and observed a client in care. The facility sketch was consistent with the current layout of the facility. No immediate health and/or safety concerns were observed.

The completed change of capacity and non-ambulatory request will be forwarded to management for final review and approval. An exit interview was conducted with Director Antonio, to whom a copy of this report and the Licensee Rights (LIC9058 01/16) were provided at the end of the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana BarfieldTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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