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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:54:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/10/2022 03:54 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: 61DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary Mc ClureTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA ) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Administrator and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 123.5 in room 237 not within the required range of 105 to 120 degrees. Fire extinguishers, carbon monoxide detector and smoke detectors are current and in compliance with fire safety requirements. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs.

LPA reviewed 12 resident and 12 staff files, including criminal record clearances. All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Appeal rights given and exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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Document Has Been Signed on 05/10/2022 03:54 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/10/2022 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2022
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Administrator sent staff to purchase a temperature gun and again lowered the thermostat during the tour and agreed to test the hot water for 3 days.
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LPA measured / tested hot water at 123,5 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a health and safety risk to resident in care.
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Test hot water in the bathroom to meet Title 22 regulations. Send 3 days hot water temperature to LPA.

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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