052700992-5-7-2025-27-AS-ELIM-DGFVJJ-20250507162847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 05/07/2025
Date Signed: 05/07/2025 04:29:01 PM

Document Has Been Signed on 05/07/2025 04:29 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	FOOTHILL VILLAGE SENIOR LIVING		FACILITY NUMBER:	052700992
ADMINISTRATOR/ DIRECTOR:	JACOB HARRYMAN		FACILITY TYPE:	740
ADDRESS:	1400 FOOTHILL VILLAGE DRIVE		TELEPHONE:	(805) 801-0404
CITY:	ANGELS CAMP	STATE: CA	ZIP CODE:	95222
CAPACITY: 78		CENSUS: 50	DATE:	05/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Jacob Harryman, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:45 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 05/07/2025, Licensing Program Analysts (LPA) Triel Lindstrom and Arielle Pascua arrived at the facility to conduct an unannounced annual inspection. LPAs Lindstrom and Pascua identified themselves, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). DFA Jacob Harryman (Administrator Certificate # 6071704740, expiration date 07/30/2026) was on-site and a brief interview followed. DFA Harryman led LPAs Lindstrom and Pascua on a tour of the facility and accompanied LPAs on their inspection of interior and exterior areas of the facility. This facility is a four-story apartment building that is licensed to serve 78 residents, including 59 nonambulatory and 19 ambulatory individuals. The facility offers licensed care on the first through third floors, including memory care on the first floor and assisted living on the second and third floors. The fourth floor is independent living. It has a hospice waiver for 6. Its fire clearance was issued by Angels Camp Fire Department on 02/08/2021. The current census is 50 residents in licensed care. The annual inspection began with a records review. LPA Lindstrom requested and reviewed three resident files and five staff files. Each staff file contained the required documentation, including First Aid/CPR certification, criminal background clearance, and TB test results. Each resident file contained the required documentation, including ofpre-appraisals, admission agreements, and physician reports.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING	FACILITY NUMBER: 052700992
	VISIT DATE: 05/07/2025

NARRATIVE

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LPAs Lindstrom and Pascua then inspected the physical plant including but not limited to the dining area, kitchen, storage rooms, common areas, resident bedrooms and bathrooms, laundry rooms, and outside patios to ensure compliance with Title 22 regulations. The Administrator Certificate, Facility License, Complaint Hotline Poster, Ombudsman information, menus, activity calendars, and resident personal rights are publicly posted.

LPAs Lindstrom and Pascua toured the kitchen and observed a two-day supply of perishable food and seven-day supply of non-perishable food, located in a storage room, walk-in freezer, and walk-in refrigerator. Food is properly stored. Appliances are in working order, except for the AC unit in the walk-in freezer. DFA Harryman stated that repairs are scheduled for tomorrow. The range hood was recently cleaned. LPAs Lindstrom and Pascua observed food debris and grease on the sides of appliances, walls, lower shelves of counter units, slip mats, and floors of the kitchens and walk-ins. Additionally, LPAs Lindstrom and Pascua observed that the linoleoum floor tiles in the kitchen and the carpet in the passage way leading into the kitchen is discolored over a large portion of it.

LPAs Lindstrom and Pascua then toured common areas intended for resident use. These were clean and odor-free. These areas have adequate furnishing, lamps, and lighting, as well as decorations on the wall. Several residents were observed sitting in these areas, talking to each other and guests. The outside patios on both the assisted living and memory care floors have outdoor chairs and tables in good repair, with views of the surrounding trees and hills.

LPAs Lindstrom and Pascua toured resident living quarters. These are clean and odor-free. Apartment units have updated appliances and fixtures, operable and intact windows and doors, and flooring in good repair. The water fixtures work, toilets flush, grab bars are present and sturdy, and non-slip mats are in good condition. LPA Pascua measured the temperature of the hot water in one resident bathroom sink. Hot water temperature was measured at 118.4 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit.

LPAs Lindstrom and Pascua then toured the locked central medication storage area. All medication is in a locked medication cart. Along with staff, LPA Lindstrom reviewed and compared medication to medication administration records.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING	FACILITY NUMBER: 052700992
	VISIT DATE: 05/07/2025

NARRATIVE

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Inside temperature was within the required regulatory range. LPA Lindstrom tested two smoke and carbon monoxide detectors and found them in working condition. There were evacuation chairs in the stairwells on each floor. The elevators were inspected on 04/12/2025.

LPA Lindstrom requested that updated copies of these documents be emailed to her by 5:00 PM on May 14, 2025:

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report
(7) LIC 309 Administrator Organization

A technical violation was issued for Section 87303(a).

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. There are no deficiencies at this time. An exit interview was conducted with DFA Jacob Harryman, and a copy of this LIC 809 report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC809 (FAS) - (06/04)

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