486800782-9-18-2024-21-AS-JNAA-D97V4F-20240917160616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800782
Report Date: 09/17/2024
Date Signed: 09/18/2024 08:18:56 AM

Document Has Been Signed on 09/18/2024 08:18 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	D HILLSIDE PLACE II		FACILITY NUMBER:	486800782
ADMINISTRATOR:	COPERO, JOHNNY		FACILITY TYPE:	740
ADDRESS:	103 MICHAEL CT.		TELEPHONE:	(707) 552-7584
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Johnny Copero, Administrator		TIME COMPLETED:	04:06 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 Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required 1 Year inspection and met with Administrator Johnny Copero. This facility is licensed for 6 Non-ambulatory residents with a Hospice Waiver approved for 1 of the residents and no Bedridden approval. There were 6 residents and 2 staff on site at the time of inspection. LPA and Administrator toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents' rooms were furnished per regulation. Water temperature in bathrooms used by residents is within the required range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Closet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies. Fire extinguishers were fully charged and last serviced May 1, 2024. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drill was conducted 08/16/2024. Staff have required First Aid and CPR certificates. Johnny "Juanito" Copero filed for renewal of Administrator's Certificate. Required postings were observed. Medication records were reviewed. Continued on 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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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: 09/17/2024

NARRATIVE

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Five staff files and five resident files were reviewed. All were complete. Residents with dementia diagnoses had current Physician's Reports. Files were very well organized.

The back yard provides nice areas for residents to sit and watch the birds at the bird feeder. Fencing in the back yard is being repaired/replaced on September 22, 2024.

LPA interviewed three residents who stated that they liked the facility and were well-cared for.

Licensee/Administrator submitted the following:

LIC 500 Personnel Summary-
LIC 610 Emergency Disaster Plan
Copy of Liability Insurance

Administrator to submit photos of new fence upon completion.

No deficiencies were found at the time of inspection. No citations were issued

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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