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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800782
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:23:20 PM


Document Has Been Signed on 07/19/2022 01:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 4DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Johnny CoperoTIME COMPLETED:
10:48 AM
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LPA A Canela arrived unannounced to conduct an Annual Required - 1 year inspection and met with Administrator, Johnny Copero. This inspection is focused on the Covid protocols of this facility.

Upon LPAs entrance to this facility and risk assessment, LPA received information the facility has Covid, LPA observed a PPE station outside the bedroom for R1 and R2. The facility and had sufficient PPE supplies but LPA was unable to complete inspection.

LPA will return to complete inspection at a later date and issue citations for reporting requirements.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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