435201737-4-14-2023-26-AS-CDOS-CQVUXA-20230414155801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201737
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:58:22 PM

Document Has Been Signed on 04/14/2023 03:58 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	HILLSIDE RANCH CORPORATION		FACILITY NUMBER:	435201737
ADMINISTRATOR:	APOSTOL, OBED		FACILITY TYPE:	735
ADDRESS:	2320 SHAFER AVENUE		TELEPHONE:	(408) 930-9872
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 6		CENSUS: 0	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Obed Apostol		TIME COMPLETED:	04:10 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 Analysts (LPAs) Christine Dolores and Manuel Monter arrived unannounced to conduct the facility's annual inspection. LPAs met with Licensee, Obed Apostol. During visit, LPAs toured the facility to include the garage, staff bedrooms, kitchen, resident bedrooms, bathrooms, living room, and backyard. All fire exits routes and passageways are free and clear of obstruction. Pool observed fenced. All staff members present are fingerprint cleared and associated to the facility. Facility has a central entry point for sign-in. Hand sanitizer made available. LPA observed COVID-19 related posters posted at the entry. Facility's temperature maintained at 57 degrees Fahrenheit. No residents observed on site. Licensee was advised to maintain the facility's proper temperature when residents return. Fire extinguisher last serviced on 04/04/2023. Facility has two operable carbon monoxide detectors. Kitchen supplied with clean cups, plates, bowls, and utensils. Facility has two refrigerator/freezers in the kitchen which stores food supplies. Refrigerator #2's temperature maintained at 18 degrees Fahrenheit. Freezer #1 temperature maintained at -20 degrees Fahrenheit. Licensee was informed all refrigerator and freezer needs to be maintained at proper temperature, therefore, needs to be equipped with a thermometer. Licensee stated understanding. Facility has 7 days worth of non-perishables and 2 days worth of perishable foods. LPAs observed the facility's cleaning supplies and knives were stored locked underneath the kitchen sink. Licensee was advised to separate the storage locations of the toxins and knives. During visit, Licensee separated the storage locations. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HILLSIDE RANCH CORPORATION	FACILITY NUMBER: 435201737
	VISIT DATE: 04/14/2023

NARRATIVE

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Facility bathrooms are equipped with hygiene products, paper supplies, lidded trash bin, non-skid mats, and hand washing sign. LPAs observed bathroom #2's bathtub to have a dirty and discolored non-slid mat. When Licensee lifted the mat, LPAs observed a cockroach crawl out of the mat. During visit, staff changed the non-skid mat.

Resident bedrooms furnished with beddings, linens, dressers, night stands, and adequate lighting / lamps. 1 out of 6 resident bedrooms observed not well maintained with dust, spider-webs, and spider next to the resident's chair. Resident's TV console observed with a layer of dust and window seal observed with a layer of dust and several deceased fruit flies. During visit, staff immediately cleaned resident's bedroom.

LPAs reviewed 3 resident files to include their admission agreement, physician's report, appraisal needs and services plan, consent forms, weight record, safeguard personal property form, safeguard of cash resources, and centrally stored medication records.

LPAs reviewed 3 staff files to include the LIC501, LIC503, First Aid Certification, IDs and training records. Licensee was informed that all staff administering medications should be trained on medication administration. Licensee was informed the training documentation should be presentable upon request. Licensee understood.

A deficiency is being cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Licensee, Obed Apostol and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2023 03:58 PM - It Cannot Be Edited

Created By: Christine Dolores On 04/14/2023 at 03:34 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: HILLSIDE RANCH CORPORATION	FACILITY NUMBER: 435201737
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(3)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the facility bathtub observed dirty with a discolored non-skid mat and cockroach was discovered when Licensee lifted the mat which poses a potential health, safety, and personal rights risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	Licensee immediately changed the non-skid mat. Licensee will ensure the bathing facilities are well maintained in a safe and sanitary condition. Licensee will submit a statement of understanding and plan of action to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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