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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604595
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:20:12 PM

Document Has Been Signed on 11/06/2024 02:20 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:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Caregiver Jave Vega and Administrator Jane AntonioTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Jave Vega. LPA then met with Administrator Jane Antonio, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all must be ambulatory. Per LIC602 Physician’s Reports, staff interviews, and LPA observation: During today’s inspection, there were a total of three (3) clients in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During today’s visit, LPA performed a welfare check and interviewed all clients in care and multiple staff. LPA also reviewed records for all clients in care and multiple staff. LPA, accompanied by the Licensee, also toured the interior and exterior of the facility, and inspected all common areas and resident bedrooms. Inside the facility was a cabinet which contained multiple bottles of cleaning chemicals, with an “automatic” lock on the cabinet door. When LPA first pulled on the cabinet door, it was not fully closed and latched, and therefore this cabinet was unlocked, in practice. In the facility’s backyard, LPA observed unlocked/accessible the following “items that could pose a danger if readily available to clients”: one (1) full-length axe with metal head, two (2) full-length post-hole digging tools with metal heads, and four (4) full-length shovels with metal spades.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 76 F. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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Document Has Been Signed on 11/06/2024 02:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 11/06/2024 at 12:55 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: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not maintain proof that 1 of 11 staff (S1) responsible for providing direct care and supervision had current first aid training, from persons qualified by agencies including but not limited to the American Red Cross. This posed a potential health and safety risk to 3 of 3 clients (Client #1 through Client #3) in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee agreed to coordinate with S1 to have them complete First Aid training from a qualified source/vendor. Licensee agreed to E-mail proof of training completion to LPA, by the POC due date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not conduct disaster drills at least quarterly for each shift. Licensee also did not vary the type of emergency covered from quarter to quarter. This posed a potential safety risk to 3 of 3 clients (Client #1 through Client #3) in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee agreed to conduct, and document in writing, competion of three (3) disaster drills (one for AM shift, one for PM shift, and one for NOC shift). Licensee agreed to E-mail proof of drill completion to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of emergency covered from quarter to quarter.
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 374604595
VISIT DATE: 11/06/2024
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[CONTINUED FROM LIC 809] Hot water temperature at taps accessible to clients were complaint in temperature: Kitchen Sink was 119.3 F, Bathroom #1 Sink was 105.3 F, and Bathroom #2 Sink was 105.6 F. Appliances to preserve perishable food were compliant in temperature: Both refrigerators were 40 F, and both freezers were 0 F. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored.

Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition were kept at the facility. No pools or bodies of water were observed on the premises. There were no open-faced heaters accessible to clients. The facility's fireplace was screened. Smoke detectors, carbon monoxide detectors, emergency lighting, night lights, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. Training records showed that staff had received training on both Personal Protective Equipment (PPE) and the facility’s written Emergency Disaster Plan within the last year, as required. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance.

During a review of records, LPA observed, and manager interview confirmed: Licensee did not have proof that Staff #1 (S1) had current First Aid training, as was required. (S1 had prior received first aid training over two years ago, but their First Aid certification card had expired). [See LIC811 Confidential Names List for a description of select person identifiers use.] While Licensee performed some disaster drills over the past year, they fell short of the required frequency of one drill per shift, per quarter. The completed drills also did not “[take] into account different emergency scenarios,” as required.

Two (2) deficiencies was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Administrator Jane Antonio. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 02:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 11/06/2024 at 01:31 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: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that cleaning solutions and other items which could pose a danger if readily available to clients, were stored where inaccessible to clients. This posed an immediate health and safety risk to 2 of 3 clients (Client #2 and Client #3) in care.
POC Due Date: 11/06/2024
Plan of Correction
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During today's visit, LPA ensured that the cabinet which contained cleaning chemicals was subsequently closed, latched, and locked. Staff also secured the metal tools secured inside a locked shed. These actions resolved the immediate risk. Licensee agreed to retrain all facility staff on what items constitute a hazard to clients if left accessible/unlocked, and to tug on doors to double-check that they are locked. Licensee agreed to E-mail the training sign-in sheet to LPA, by 12/06/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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