496801208-10-10-2023-21-AS-CCOO-CWGUN6-20231010154325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801208
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:43:41 PM

Document Has Been Signed on 10/10/2023 03:43 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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: 5	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Administrator Rosa Soto		TIME COMPLETED:	03:58 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	On 10/10/2023 Licensing Program Analysts Cuadra and Coppo conducted an annual inspection and was greeted by Administrator, Rosa Soto. This annual inspection is being conducted with current Administrator. LPAs/Administrator toured the facility inside and outside. At approximate 9:00am LPAs/Administrator observed resident (R1) downstairs has been sleeping in the library area. LPA advised to move resident back in their room per fire clearance requirements and take non-hospital bed out of their room in order to place hospital bed in room. Administrator to ensure that resident is not sleeping in library area and is moved into their room each and every night. Also, two fireplaces, one downstairs and one upstairs as well as a gas stove downstairs all need to be adequately covered, per Title 22 regulation 87307(7)(See LIC 9102). At approximately 9:30am LPAs/Administrator observed the water temperature to measure 93.7 in downstairs resident bedroom, and water temperature measured 108.7 degrees F in residents' upstairs bedrooms. Per Title 22 regulation 87303(B)(2), temperatures 93.7 F and 108.7 F are outside and within regulation (between 105 and 120 degrees F) in faucets used by residents, respectively (See LIC 9102). LPAs/Administrator observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 6 residents in care. However, there were some canned goods found to be expired. Three cans of Vienna Sausages were expired as of 06/06/2019. One can of vegetable soup expired as of 07/26/23. Per Title 22 regulation 87555.(See LIC 9102) LPAs advised that all resident beds should have mattress pads per Title 22 regulation 87307. (See LIC 9102) Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HILL HOUSE, THE	FACILITY NUMBER: 496801208
	VISIT DATE: 10/10/2023

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
26
27
28
29
30
31
32

continued from 809..

At approximately 10:00am LPAs observed that the exit located upstairs, leading to outside staircase, was unlocked and alarm was off. Outside staircase is very steep. LPAs advised Administrator that alarm must be fixed and operational, as dementia residents are in care and the exit is in close proximity to their rooms. Per Title 22 regulation 87303 (a) Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (See LIC 809D). Also, At approximately 11:00am LPAs followed up on last Technical Assistance issued on 4/14/23 for expired elevator permit. Per letter provided by Administrator dated 4/18/2023 request for valid permit is processing. Per Title 22 regulation 87303 (See LIC 809D) elevator permit required to be current. Two of two fire extinguishers throughout the facility were found to be last charged on 04/14/2023. Smoke detectors and carbon monoxide detectors were tested in common areas and client bedrooms all of which were found to be in working order. Last disaster drill conducted 7/2023.

At approximately 12:30pm LPAs asked Administrator if the facility had an evacuation chair for the stairwell, as one is required per H&S code 1569.695. Administrator indicated they do not have an evacuation chair for the stairwell(See LIC 809D).

LPAs/Administrator conducted file review at 1:00pm. Files were not maintained with current forms. LPAs advised Administrator to review and organize them as required by regulation. LPAs provided guidance and provide them with a list of required items to be maintained in records on site at all times. (See LIC 9102).

Administrator Certificate for Rosa Soto expiration date 8/29/2025

Administrator will be sending to CCL a copy of the updated:
LIC 308
LIC 500
Plan of Operation

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview was conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 10/10/2023 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HILL HOUSE, THE	FACILITY NUMBER: 496801208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Administrator observation, the licensee did not comply with the section cited above in that the exit located upstairs, leading to outside staircase, was unlocked and alarm was off. Also, elevator permit was expired. Both deficiency pose an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator to submit plan of correction (POC) to get the alarm functional and operational as well as follow up with elevator permit processing to see when it can be issued. Once items are fixed Administrator agrees to provide proof of service and also sumbit Self-Certification LIC 9098 by POC due date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 10/10/2023 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HILL HOUSE, THE	FACILITY NUMBER: 496801208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Administrator observation, the licensee did not comply with the section cited above as there were some canned goods found to be expired. Three cans of Vienna Sausages were expired as of 06/06/2019. One can of vegetable soup expired as of 07/26/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator discarded expired food when LPAs were present at facility.

Type B

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Administrator observation, the licensee did not comply with the section cited above, Administrator indicated they do not have an evacuation chair for the stairwell which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to ensure facility obtains an evacuation chair for the stairwell by POC correction date of 10/24/2023

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 8