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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421704099
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:27:23 PM


Document Has Been Signed on 09/15/2022 02:27 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:HILLVIEW RESIDENCEFACILITY NUMBER:
421704099
ADMINISTRATOR:SHERI DROMFACILITY TYPE:
740
ADDRESS:3705 HILLVIEW ROADTELEPHONE:
(805) 937-2360
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:48CENSUS: 25DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rachel Dron/Care MangerTIME COMPLETED:
01:00 PM
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 At 10:00am on 09/15/2022, Licensing Program Analyst (LPA) Jeffries, arrived at the facility unannounced to conduct an annual infection control inspection. LPA was properly screened upon entrance to the facility. LPA met with facility Care Manager, Rachel Dron (Staff1, S1) and introduced himself and announced the reason of the visit.

At 10:35am S1 and LPA conducted a cursory tour of the facility. The facility is a 25 bed room, 21 bathroom, 1 kitchen, 2 dining rooms, 2 large common rooms and a very large courtyard. There is storage and a detached Administrators Office with more storage in the back of the facility LPA observed more than a 30 day supply of PPE in the back storage. LPA noted that the facility fire inspection was conducted on 06/03/2022 by Alpha Fire. LPA observed two days of perishable and seven days of nonperishable foods in the facilities kitchen storage. LPA noted all rooms toured were clean and all bathroom had liquid soap and paper towels stocked in the bathroom. LPA did not note any visible hazards during the tour that would put residents in jeopardy. LPA reviewed staff current working on this day for clearance and all staff were cleared to work.

At 11:00am S1 and LPA conducted the infection control portion of the annual visit. At this time LPA did not discover any violations and no citations were accessed.

Exit interview, report signed and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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