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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201737
Report Date: 03/24/2024
Date Signed: 03/24/2024 10:07:17 AM

Document Has Been Signed on 03/24/2024 10:07 AM - 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 CORPORATIONFACILITY NUMBER:
435201737
ADMINISTRATOR:APOSTOL, OBEDFACILITY TYPE:
735
ADDRESS:2320 SHAFER AVENUETELEPHONE:
(408) 930-9872
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 3DATE:
03/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Staff Alberto PagsisihanTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Alberto Pagsisihan. During the visit, LPA observed 3 residents and 1 staff.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 107 degrees F in both resident bathrooms.
Fire extinguisher was serviced in April 4, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 1, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents. LPA requested to review residents P&I records. Staff S1 stated facility ADM went on vacation on March 3, 2024 and is returning on March 24, 2024. Staff S1 stated the ADM has the key for the P&I records, but left cash for residents to spend. S1 stated the cabinet which contains the P&I records is locked and the ADM took the key. LPA called Designated Administrator Naomie Apostol Miles at 9:22am and 9:46am. No answer, LPA left voicemail. LPA called the facility Administrator at 9:49am, no answer. LPA left voicemail.

A deficiency is being cited during today's visit. This report was reviewed with Staff Alberto Pagsisihan and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2024
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 03/24/2024 10:07 AM - It Cannot Be Edited


Created By: Manuel Monter On 03/24/2024 at 09:52 AM
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: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review residents P&I records. Staff S1 stated facility ADM went on vacation on March 3, 2024 and took the cabinet key, which has the P&I records inside. LPA called Designated Administrator Naomie Apostol Miles at 9:22am and 9:46am. No answer. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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ADM stated he will send a written letter of understanding regarding the regulation, and why its important to have residents records available to the licensing agency to inspect and audit. ADM stated he will send the POC by March 29, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024


LIC809 (FAS) - (06/04)
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