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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 04/23/2021
Date Signed: 04/30/2021 10:26:00 AM

Document Has Been Signed on 04/30/2021 10:26 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:BITLER, MAUREEN H.FACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: 55DATE:
04/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:M. Hope BitlerTIME COMPLETED:
02:15 PM
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LPA Albert Johnson arrived unannounced at the facility and was met by Hope Bitler (Administrator).

LPA conducted a tour inside and outside the facility. LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed resident's rooms and living areas to be adequately furnished.

LPA observed adequate supply of linens and first aid kits. Emergency exit and phone number are posted. LPA tested water temperature in resident bathroom (133) at 119 degrees F. LPA observed bathroom facilities to be functioning properly. Cleaning supplies and chemicals are stored in locked cabinets. Medications and confidential paperwork are stored in locked areas. LPA waived the Component III.

Fire clearance is for 78 total of which 19 AMBULATORY residents and 59 NON AMBULATORY(1st and 2nd floor only). Activity supplies available. LPA observed fully charged fire extinguishers. Smoke alarms and Carbon Monoxide detector operational. Facility telephone number is (209) 729-2200.

This report will be forwarded to the centralized application unit for continued processing.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2021
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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