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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801208
Report Date: 04/14/2023
Date Signed: 04/14/2023 09:52:18 AM


Document Has Been Signed on 04/14/2023 09:52 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: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: 4DATE:
04/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caregiver #1, Rosa SotoTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hill House,The for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Caregiver #1, Rosa Soto, and was granted access into the facility. Community Care Licensing was notified on April 13, 2023 that the Licensee has passed away.

During the course of the Case Management-Other inspection, LPA toured the facility with Caregiver #1 and found the facility to be clean at a comfortable temperature with all exits free from obstruction. LPA observed sufficient perishable and non-perishable foods. LPA observed the electricity being on and operable at the time of the inspection. Hot water temperature measured at 111 degrees in resident bathrooms, and is within Title 22 regulation of 105 to 120 degrees F. Bathrooms contained necessary grab bars and non-slip floors. During the tour of the facility with Caregiver #1, LPA observed that the Elevator Permits have expired in February 28, 2021 (See LIC 812-Photo & LIC 9102). In addition, LPA observed 2 of 2 fire extinguishers being expired. LPA was informed by the Caregiver that an inspector will be coming out to the facility to inspect the fire extinguishers (See LIC 9102). LPA requested the following documents:

-Staff Roster
-Resident Roster
-Copy of Death Certificate of Licensee

No deficiencies were cited during today's Case Management-Other inspection. Exit interview conducted with Caregiver #1, and a copy of this report was printed and given to Caregiver #1.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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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