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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201105
Report Date: 06/28/2022
Date Signed: 06/28/2022 04:51:21 PM

Document Has Been Signed on 06/28/2022 04:51 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HILLSDALE HOMEFACILITY NUMBER:
435201105
ADMINISTRATOR:JOHN TANAKAFACILITY TYPE:
735
ADDRESS:318 LOS PINOS WAYTELEPHONE:
(408) 599-9597
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 4DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Elizabeth fox and John TanakaTIME COMPLETED:
05:00 PM
NARRATIVE
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On 06/28/2022, Licensing Program Analysts Mandeep Kaur and Christine Dolores (LPAs) conducted an unannounced annual inspection. LPAs met with facility Staff Rosa Cervantes. After 10 minutes, Administrator John Tanaka and Program Manager Elizabeth Fox joined the LPAs.

Upon arrival, LPAs observed the "No Visitor" sign posted on the front door. LPAs advised of the visitor guidelines and staff immediately removed the No visitor sign.

Staff did not take LPAs' temperature nor screened LPAs for the COVID symptoms. 30 days supply of PPE was observed. Social distancing, symptoms and warning signs of COVID, and cough etiquette signs observed to be posted in all public areas. LPAs toured the facility, including living room, kitchen, dining room, laundry room, 3 resident bedrooms, 1 staff room, 2 bathrooms, and back yard. All emergency exits noted to be clear of obstruction. LPAs observed paper supplies and hygiene supplies in the bathrooms. LPAs advised to place the hand washing signs in the bathrooms and during visit, administrator placed the hand washing signs in the bathrooms. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. All cleaning supplies and chemicals noted to be in locked cabinets and closets.

AT 2:22PM, LPAs observed the 3 unsecured knives on the kitchen counter. Staff immediately secured the 3 knives. LPAs observed the floor to contain dirt and the dark spots. Staff stated that they mop the floor every two weeks. LPAs observed spider webs along the wall of the living room. LPAs observed the residents' dirty laundry piled on the floor of the garage. Staff stated that laundry gets done once a week by the residents.
Administrator confirmed that all staff and residents have been vaccinated and Boosted.
Deficiencies were cited per California Code of regulations Title 22. Advisory notes provided
This report was reviewed with Administrator John Tanaka and Program Manager Elizabeth Fox . A copy of the signed report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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Document Has Been Signed on 06/28/2022 04:51 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 06/28/2022 at 04:14 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HILLSDALE HOME
FACILITY NUMBER: 435201105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

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 observation and interview, the licensee did not ensure to secure the knives on the kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
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Staff Immediately secured the knives in the locked cabinet. Licensee will review section 80087 and send a statement of understanding via email to LPA by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/28/2022 04:51 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 06/28/2022 at 04:14 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HILLSDALE HOME
FACILITY NUMBER: 435201105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, LPAs observed the floor to contain dirt and dark spot, spider webs along the wall in the living room and the residents' dirty laundry piled up on the garage floor which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will ensure to maintain the floors of the facility and clean the spider webs off of the wall in the living room. Licensee will create a plan to ensure that the residents' dirty clothes are not piled on the garage floor. Licensee will send the Plan of correction to LPA via email by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Sarah Yip
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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