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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801208
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:47:51 PM


Document Has Been Signed on 09/15/2022 03:47 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:HILL HOUSE, THEFACILITY NUMBER:
496801208
ADMINISTRATOR:HILL, RALPHFACILITY TYPE:
740
ADDRESS:8840 EGG FARM LANETELEPHONE:
(707) 833-1157
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator, Ralph Hill & Rosa SotoTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/15/2022 to conduct a Required - 1 Year inspection. This inspection was focused on the infection control practices and procedures of this facility. LPA met with Administrator, Ralph Hill and Rosa Soto.

During the inspection LPA toured building and grounds which were clean and in good repair. All exits and walkways were free from obstructions. Facility is a two story building with resident bedrooms on the first and second floor. Resident bedrooms were furnished as necessary. Bathrooms were equipped with necessary grab bars and non-slip mats. There was a sufficient amount of perishable and non-perishable food available for residents. Toxins were inaccessible to residents in care. Medications were locked and inaccessible. Resident and staff files were available for review. LPA and administrator discussed necessary documentation for resident and staff files. LPA and administrator discussed training and CPR/First Aid requirements for staff. Staff and residents are vaccinated and boosted. High touch surface areas are disinfected daily.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 - Designation of Facility Responsibility
LIC 610E - Emergency Disaster Plan
LIC 9020- Resident Roster
LIC 500 - Personnel Report
Evidence of Liability Insurance

Exit interview conducted with Rosa Soto and a copy of this report printed for the facility. No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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