496801208-8-6-2021-21-AS-EGCS-C5MPXG-20210806114218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801208
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:42:24 AM

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:	HILL HOUSE, THE		FACILITY NUMBER:	496801208
ADMINISTRATOR:	HILL, RALPH		FACILITY TYPE:	740
ADDRESS:	8840 EGG FARM LANE		TELEPHONE:	(707) 833-1157
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	6	CENSUS: 6	DATE:	08/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator, Ralph Hill & Rosa Soto		TIME COMPLETED:	11:55 AM

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), Erik Gonzalez Campos arrived unannounced to conduct a required - 1 year inspection at approximately 10:15 AM, and met with administrator Ralph Hill and staff Rosa Soto. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed thermometer and hand sanitizer for use on visitors upon entry. LPA conducted walk through of the facility with Rosa Soto and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to residents and responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked laundry room cabinets. A 30 day supply of medications are stored in a locked kitchen cabinet making them inaccessible to residents. Facility is currently not testing per CCL guidelines since vaccination rate for staff and residents is greater than 70 percent. Continued on LIC 809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: HILL HOUSE, THE	FACILITY NUMBER: 496801208
	VISIT DATE: 08/06/2021

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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and staff discussed resident activities which include exercises and music. Visits are occurring on the outdoor patio area.

Administrator and LPA discussed that facility will potentially apply to increase capacity to 10 residents.

LPA requested the following documents during visit:

LIC 308 - Designation of Facility Responsibility
LIC 610E - Emergency Disaster Plan
LIC 9020- Resident Roster
LIC 500 - Personnel Report
Copy of current admin certificate
Copy of current liability insurance

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC809 (FAS) - (06/04)

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