496803379-3-10-2022-21-AS-SHAN-CCDVYQ-20220310155131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803379
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:51:37 PM

Document Has Been Signed on 03/10/2022 03:51 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 TERRACE		FACILITY NUMBER:	496803379
ADMINISTRATOR:	CASTANEDA, RAMIRO ERNESTO		FACILITY TYPE:	740
ADDRESS:	922 COTTONWOOD COURT		TELEPHONE:	(707) 981-7784
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	5	CENSUS: 0	DATE:	03/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kevin Castaneda - Licensee		TIME COMPLETED:	03:50 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1-year infection control inspection of the facility. LPA was welcomed by Licensee Kevin Castaneda. Facility has no residents at this time while construction is being completed on facility. Last resident was placed in other facility in December 2021. Facility tour/inspection began at 10:45 AM: LPA toured the facility on 3/10/2022 at 3:00 PM with Kevin Castaneda; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices that were working properly during the visit. Fire Extinguisher was found to be last charged on 11/10/2021 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured 118.7 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 out of 2 resident’s bathroom faucets while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. Toxins are stored in the garage. There was a supply of cleaners, hygiene products and paper products available. The bathroom designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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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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: HILL TERRACE	FACILITY NUMBER: 496803379
	VISIT DATE: 03/10/2022

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Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 3/18/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in garage. Staff had all PPE training required as well have been N95 Fit Tested. All staff have been fully vaccinated and received their COVID booster shots and all staff work exclusively at this facility.

Facility conducts disaster drills monthly with the last being 12/2021.

LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; no need to change any of the information other than add Licensee’s cell number. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

As facility is under construction of minor/cosmetic upgrades along with maintenance, licensee will contact CCL for possible inspection prior to accepting any residents.

LPA was presented with current Administrator Certificate for Ramiro Castaneda #6015597740 Expiration 4/21/2022

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/31/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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