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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 10/28/2021
Date Signed: 10/28/2021 04:43:56 PM

Document Has Been Signed on 10/28/2021 04:43 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, 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: 49DATE:
10/28/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Excutive Director Hope BitlerTIME COMPLETED:
05:00 PM
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LPA Jason Lund met CDPH HAI Shantala Stanya arrived at the facility for infection control training. LPA and HAI met with Executive Director Hope Bitler. The census was 49, with 3 residents on hospice. Shantala provided information and instruction on isolating testing and infection control practices. Questions answered on the isolation of residents, testing and staffing concerns. Also discussed were visitation requirement, Dining and activities are closed until the facility is cleared.

A tour of the facility was conducted. LPA observed physical plant was clean and in good repair. There is an exterior hand washing station where all staff and visitors enter the facility. PPE and the visitor's log were observed. Staff screen at the beginning and end of the shift. Soap, sanitizer, and paper towels were available at kitchen hand washing sink. Meals were served in rooms at this time. PPE and sanitizer is available throughout the facility. There is an entire room dedicated to PPE storage and regularly tracked inventory. Staff restroom was stocked with soap, sanitizer, paper towels. Employees are breaking in lobby and activities director is responsible to clean the tables in-between use. All residents live in individual apartments with restroom, kitchen, and living room.

Exit interview conducted and a copy of the reported provided to the Administrator.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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