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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804165
Report Date: 08/04/2023
Date Signed: 08/25/2023 09:00:35 AM


Document Has Been Signed on 08/25/2023 09:00 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:HILL HOUSE, THEFACILITY NUMBER:
496804165
ADMINISTRATOR:SOTO LUGO, ROSA I.FACILITY TYPE:
740
ADDRESS:8840 EGG FARM LANETELEPHONE:
(707) 332-4494
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:6CENSUS: 5DATE:
08/04/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH: Fortino Soto; Ivan Soto Lugo - CEO/ Rosa Soto Lugo AdministratoTIME COMPLETED:
12:43 PM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW -EAO
Capacity: 6
Census (if any clients in care): 5

COMP II Participants: Fortino Soto; Ivan Soto Lugo - CEO/ Rosa Soto Lugo Administrator
Interview Method: Telephone interview

On August 4, 2023, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the
following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-Licensing Readiness
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Ricmar SorianoTELEPHONE: (916) 617-7083
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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