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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401703837
Report Date: 11/01/2021
Date Signed: 11/01/2021 11:56:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HILLSIDE VILLA RETIREMENT HOMEFACILITY NUMBER:
401703837
ADMINISTRATOR:RAY, CONNIEFACILITY TYPE:
740
ADDRESS:547 MAY STREETTELEPHONE:
(805) 473-8097
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: 4DATE:
11/01/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Connie RayTIME COMPLETED:
11:37 AM
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Licensing Program Analyst (LPA) De Leon arrived at the facility to meet with Licensee Connie Ray for a technical support visit with LPA and Public Health Infection Prevention Nurse Jeannette Tosh from San Luis Obispo County Public Health. The purpose of the visit had a specific emphasis on infection control practices.

Upon entry into the facility, LPA found all required signs on or near the front door. The facility has a central entry point for signing in, symptom screening, and temperature checks. The facility has appropriate signs in the common spaces to promote proper hand hygiene, physical distancing, and symptom reporting. Staff were observed wearing N95 masks, gowns, gloves and face shields. Hand sanitizer was available throughout the common spaces for resident and staff use.

During today's visit, discussion took place regarding the current status of positive residents and staff, testing, communication to staff and families, symptom screening, signs, and procedures around visitation. The facility is not experiencing any issues with staffing. Cleaning and disinfectant protocols are adequate and Nurse is asking for facility to check all disinfectants and make sure they are approved by the EPA.

No health and safety hazards noted during today's visit. Exit interview conducted. A copy of the report was emailed to the Licensee to sign and return to LPA.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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