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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800782
Report Date: 08/03/2021
Date Signed: 08/03/2021 01:10:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:D HILLSIDE PLACE IIFACILITY NUMBER:
486800782
ADMINISTRATOR:COPERO, JOHNNYFACILITY TYPE:
740
ADDRESS:103 MICHAEL CT.TELEPHONE:
(707) 552-7584
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Administrator, Johnny CoperoTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at D Hillside Place II unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, Johnny Copero. LPA was granted access into the facility.

LPA conducted a tour of the facility with the Administrator and made the following observations, facility was at a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 119.8 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. First aid kit was stocked. Fire extinguisher was last inspected August 2020. Smoke detectors and Carbon monoxide detector was tested and operational. Exit doors have auditory alert system and were functional at time of visit. Medications were centrally stored and locked. Last Emergency Disaster Drill was conducted on May 2021. LPA discussed Annual Fees with the Administrator. LPA requested the following documents be sent:
LIC 610D-Emergency Disaster Plan, LIC 309-Administrative Organization, LIC 400-Affidavit regarding Resident cash resources, LIC 308-Designation of Facility Responsibility, Liability insurance, LIC 500-Personnel Report and LIC 402-Surety Bond (if applicable).

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage room. Staff have had all PPE training required and will be in the process of obtaining N95 Fit testing for employees. Mitigation Plan reviewed at the facility.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Johnny Copero.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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