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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800782
Report Date: 11/08/2022
Date Signed: 11/09/2022 01:20:17 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/09/2022 01:20 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: 6DATE:
11/08/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Johnny CoperoTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced, to continue an Annual Required 1 YR inspection and was greeted by Administrator, Johhny Copero. The inspection is focused on the Infection Control procedures and practices of this facility

Upon arrival, LPA observed facility staff are wearing masks, front entrance has Covid posters and a sign-in for visitors, screening area with PPE in the front porch. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms and paper towels. Facility was a comfortable temperature. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected throughout the day.

Facility staff have been trained on PPE and Facility has submitted their Covid-19 Mitigation Plan and it was approved. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication.

LPA was unable to do a walk of the backyard due to the heavy rain. LPA went over admission agreement to address the use of cameras. LPA requested an updated facility sketch, that is fully completed.

Continue report See LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 486800782
VISIT DATE: 11/08/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 11/30/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report (provided during visit)
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond, if applicable
· LIC 610D Emergency Disaster Plan (provided during visit)
· LIC 9020 Register of Facility Residents
· Copy of current, updated facility Sketch
· Copy of Liability insurance
· Copy Administrator Certificate
· Copy of Admission Agreement


Exit interview conducted with Johnny Copero, Licensee/Administrator.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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