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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201105
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:55:42 PM

Document Has Been Signed on 06/26/2024 04:55 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/
DIRECTOR:		JOHN TANAKAFACILITY TYPE:
735
ADDRESS:318 LOS PINOS WAYTELEPHONE:
(408) 599-9597
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 4DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:John TanakaTIME VISIT/
INSPECTION COMPLETED:
04:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) John Tanaka .

LPA observed 2 staff and 2 residents in the facility. LPA observed a visitor (V1) in the living room. ADM stated V1 helps for grocery shopping.

LPAs checked 2 resident record files (R1 - R2) and 2 staff record files (S1 - S2).

LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and two restrooms were inspected. Three shared resident bedrooms, garage, and laundry room were inspected. One staff live-in room was observed in facility. One of the three resident bedrooms was observed without screen window. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet were observed locked. Dish washing soap liquid bottle was observed placed on the kitchen counter. ADM placed the dish washing soap liquid bottle in a closet and locked it before LPA finished the annual inspection. Room temperature was at 74 degree F, and hot water temperature was at 107 degree F in facility. First aid box, flash lights and night lights were observed in the facility.

Fire extinguisher was observed on service on 05/06/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. The last time the facility conducted the emergency drill is on 5/3/2024.

Deficiencies were noted today. Exit interview was conducted with ADM. The report were provided to ADM for signature. LIC809-D and Appeal Right were attached. A copy of the report were provide to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/26/2024 04:55 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/26/2024 at 03:24 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: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that a person (V1) was observed in the facility who Administrator stated helping the facility for grocery shopping. V1 has no criminal record clearance document. This poses an immediate health, safety risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Administrator stated to send a plan of correction by the 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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/26/2024 04:55 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/26/2024 at 03:24 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: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, the licensee did not comply with the section cited above in that dish washing soap liquid bottle was observed placed on the kitchen counter which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Administrator stated the submit a plan of correction by the POC due date to keep dish washing soap liquid bottle locked when not used.

ADM locked the dish washing soap liquid bottle before LPA finished annual inspection..
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that one of the three resident bedrooms was observed without screen window which poses/posed a potential health, safety to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due to install a screen window for the resident bed room.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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