401703837-12-3-2024-29-AS-RDLN-DBLUB5-20241203142547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 401703837
Report Date: 12/03/2024
Date Signed: 12/03/2024 02:25:56 PM

Document Has Been Signed on 12/03/2024 02:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILLSIDE VILLA RETIREMENT HOME		FACILITY NUMBER:	401703837
ADMINISTRATOR/ DIRECTOR:	RAY, CONNIE		FACILITY TYPE:	740
ADDRESS:	547 MAY STREET		TELEPHONE:	(805) 473-8097
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Connie Ray, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon arrived at 11:15am to conduct a 1 year annual visit to the facility above. LPA met Administrator Connie Ray and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current infection Control Plan on file. The facility has a sign in and out note pad with hand sanitizer at garage door entry. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environmental Safety: The facility is a 3 bedroom and 3 bathroom currently occupying 6 residents and employs 7 staff, 1 Administrator and 1 back up staff if needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in garage or under locked kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard for client use. The facility has a gate one on each side of the house that is self closing and self latching. The facility has telephone and internet service for resident use. Continued 809-C

Kelly Burley	TELEPHONE: (805) 562-0413
Rachael De Leon	TELEPHONE: (805) 450-0262
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLSIDE VILLA RETIREMENT HOME	FACILITY NUMBER: 401703837
	VISIT DATE: 12/03/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/01/2025. The facility is approved for a capacity of 6 Non- Ambulatory and Hospice waiver approved for 3 residents.

Staffing: The facility employes 7 staff, 1 Administrators and 1 additional back up staff when needed. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions on file. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator's Certificates expired on 10/26/2024, currently on pending list.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for 2024 Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements, PPE and Quarterly Disaster Drills. Staff handling medications had required 8 hours of medication training. Trainers meet requirements to train staff. Initial staff training was kept on file.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit resident incident reports to the department when required.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLSIDE VILLA RETIREMENT HOME	FACILITY NUMBER: 401703837
	VISIT DATE: 12/03/2024

NARRATIVE

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Incidental Medical & Dental: The facility has a locked medication cabinet in the medication room/office. Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected residents medications for all prescription and PRN medications with Doctors orders, no medications labels were altered, medications are stored in original containers and no medications were expired. The facility has a locked box for refrigerated medications if required. In an evacuation medications will be placed in ice chest with ice packs to keep cold if utilities are affected. The facility has a red sharps container for disposal of syringes. Administrator and 1 other staff take medications to the pharmacy for destruct.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 07/31/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility capacity in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility does not currently have any residents using oxygen. The facility currently has hospice residents in care. The facility does not currently have any resident on Home Health services. The facility has working exiting door alarms for the safety of residents in care.

LPA conducted interviews with 3 staff and 3 residents.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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