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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804165
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:29:12 PM


Document Has Been Signed on 10/30/2023 02:29 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 HOUSE, THEFACILITY NUMBER:
496804165
ADMINISTRATOR:LUGO SOTO, ROSA I.FACILITY TYPE:
740
ADDRESS:8840 EGG FARM LANETELEPHONE:
(707) 332-4494
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:6CENSUS: 3DATE:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Rosa & Ivan Soto (Administrator/Applicants)TIME COMPLETED:
02:44 PM
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Licensing Program Analyst Cuadra arrived announced to conduct a sub-sequent pre-licensing Continuation Facility Inspection and met with Applicants/Administrator Rosa Soto and Ivan Soto. A pre-licensing inspection was completed on 10/10/2023.

During today’s visit LPA observed the following items were within Title 22 compliance:

· Fireplaces are covered inaccessible to residents in care.
· Expired food was discarded.
· Beds for residents in care have mattress pads.
· Upstairs exit leading to outside staircase was locked and alarm was on.
· Resident (R1) sleeps in their bedroom.

Component III was conducted with Applicants, which have satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.

No deficiencies cited at today’s inspection.

This report was reviewed with applicant and a copy was provided to the Applicants.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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