496804165-10-10-2023-21-AS-CCOO-CWGUPH-20231010154534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804165
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:45:38 PM

Document Has Been Signed on 10/10/2023 03:45 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:	496804165
ADMINISTRATOR:	LUGO SOTO, ROSA I.		FACILITY TYPE:	740
ADDRESS:	8840 EGG FARM LANE		TELEPHONE:	(707) 332-4494
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	6	CENSUS: 5	DATE:	10/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Adminstrator Rosa Soto		TIME COMPLETED:	04:00 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 a pre-licensing inspection and was greeted by Adminstrator/Applicant, Rosa Soto. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 6 nonambulatory clients. Hospice waiver approved for two residents. LPAs/Administrator conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. 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 Facility is two stories with one resident room located downstairs and all other bedrooms located upstairs. The upstairs is accessible via an indoor elevator which was tested and functional. The facility was found to be clean and a comfortable temperature. LPAs/Administrator observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 5 residents in care. Sharp knives are stored in a locked drawer in the kitchen. Water temperature measured 93.7 in downstairs resident bedroom, and water temperature measured 108.7 degrees F in residents' upstairs bedrooms. 93.7 F and 108.7 F are outside and within regulation between 105 and 120 degrees F in faucets used by residents, respectively. There was an ample supply of linens, cleaners, hygiene products and paper products available for residents. Toxins were inspected and are located in a locked cabinet off the kitchen area. All residents' bathrooms contained necessary grab bars and non-slip floors/mats. Medication is centrally stored in a locked cabinet off the kitchen area. All bedrooms are equipped with lighting and proper bedding which was clean and in good repair. Continued on 809C......

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)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HILL HOUSE, THE	FACILITY NUMBER: 496804165
	VISIT DATE: 10/10/2023

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Continued from 809...

Fire clearance issues found: resident sleeping in the library area. Two fireplaces, one downstairs and one upstairs as well as a gas stove downstairs all need to be adequately covered as well as a gas stove downstairs. Some canned goods were found be expired. Beds did not have mattress pads. Upstairs exit leading to outside staircase was unlocked and alarm was off. Deficiencies observed by LPAs/Administrator are cited on current license #496801208.

Component III was not conducted with Applicant. LPA will submit copy of the facility report to the Centralized Application Unit and inform of citations. LPA to conduct subsequent pre-licensing inspection after POCs are cleared.

This report was reviewed with applicant and a copy was provided to the Licensee.

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)

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