<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613199
Report Date: 05/01/2023
Date Signed: 05/01/2023 03:06:33 PM


Document Has Been Signed on 05/01/2023 03:06 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:FOX HILLS BOARD & CARE HOMEFACILITY NUMBER:
300613199
ADMINISTRATOR:HERNANDEZ, DIANA GALVEZFACILITY TYPE:
735
ADDRESS:5361 FOX HILLS AVENUETELEPHONE:
(714) 928-4968
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:8CENSUS: 7DATE:
05/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Diana Galvez Hernandez, AdministratorTIME COMPLETED:
03:06 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 today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced case management visit to the facility in conjunction with complaint visit 22-AS-20230421093310. LPA Quiroz was greeted and granted entry into the facility, met with Administrator Diana Galvez Hernandez and explained the reason for the visit.

While conducting interviews with interviewees for Complaint control #22-AS-20230421093310, LPA Quiroz observed the following deficiencies:
  • Food Service:85076:(a)(1)
  • Personal Rights 80072:(a)(1)(3)



Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator Diana Hernandez, and a copy of this report, LIC 809-D, LIC 811- Confidential Names and Appeal Rights were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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 2


Document Has Been Signed on 05/01/2023 03:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: FOX HILLS BOARD & CARE HOME
FACILITY NUMBER: 300613199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2023
Section Cited

1
2
3
4
5
6
7
Food Service:85076(a)(1):
(a) In facilities providing meals to clients, the following shall apply:(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
AD Diana Hernandez agreed to read and understand CCR Food Service: 85076 and provide training to staff on CCR Food Service: 85076 and submit proof to CCL by 5/8/2023. AD agreed to maintain a sufficient supply of perishable and non-perishable items including CONTINUE BELOW...
8
9
10
11
12
13
14
Based on interviews conducted with interviewees, interviews revealed facility is not providing clients in care with snacks. This deficiency posed a potential risk to the health, safety and personal rights of the individuals in care.
8
9
10
11
12
13
14
CONT...snacks for clients in care and commence a log of refusal of snacks.
Type B
05/02/2023
Section Cited

1
2
3
4
5
6
7
80072 Personal Rights(a)(1)(3):(a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons to interference with the daily living functions...
1
2
3
4
5
6
7
Administrator Diana Hernandez agreed to remove Direct Service Provider 1 from schedule immediately.
8
9
10
11
12
13
14
CONT...(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions...This requirement is not met as evidenced by 4 of 4 CONT...
8
9
10
11
12
13
14
CONT...interviewees indicated
(DSP) 1 ridicules, intimidates, verbally abuses clients and is punitive to clients in care. This poses a potential risk to clients in care.
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2