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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201737
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:06:38 PM

Document Has Been Signed on 03/10/2022 03:06 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:HILLSIDE RANCH CORPORATIONFACILITY NUMBER:
435201737
ADMINISTRATOR:APOSTOL, OBEDFACILITY TYPE:
735
ADDRESS:2320 SHAFER AVENUETELEPHONE:
(408) 930-9872
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 6DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:APOSTOL, OBEDTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection and met with Administrator Obed Apostol.

During visit, LPA toured the facility inside and outside to include the central entry point, bathrooms, resident rooms, living room, dining room, kitchen, and backyard.

Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms. Trash cans were observed with lid. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE). Facility staff are trained on donning and doffing PPE. All staff observed to be wearing a face mask.

LPA observed the following posters to include symptoms of COVID, face mask do or dont's, protect yourself from COVID Facility disinfect and sanitize high touch surfaces daily and as needed.

During visit, facility created a screening station for all visitors, residents, and staff upon entry. The following documents were obtained to include updated LIC-500, LIC-610D, and Administrator Certificate.

No deficiencies cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator Obed Apostol and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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