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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 08/29/2025
Date Signed: 08/29/2025 05:50:38 PM

Document Has Been Signed on 08/29/2025 05:50 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 LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR/
DIRECTOR:		JACOB HARRYMANFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: DATE:
08/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jacob Harryman, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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On 8/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom visited the facility unannounced to conduct a case management visit regarding the fire that occurred at the facility the morning of 8/26/2025. LPA Lindstrom met with Administrator Jacob Harryman (S1), introduced herself, and explained the purpose of the visit.

LPA Lindstrom interviewed S1, S2, and S3. S1 stated that on 8/26/2025, a fire broke out in the living room of a resident’s apartment (R1). R1 was in the apartment at the time of the fire. Staff (S2) rescued R1 within moments of the smoke alarm sounding in their apartment and staff evacuated all residents and staff from the facility within ten minutes. S2 stated that they determined that the alarm was sounding in R1’s apartment, entered R1’s room, and saw R1 sitting in a chair on their balcony. S2 observed smoke and flames about a foot high in the corner of the living room near an outlet located on the back of a kitchen counter. S2 stated that they observed R1’s oxygen concentrator in this corner near the outlet and that the oxygen concentrator tubing that stretched from the machine, across the living room, and beneath the balcony door was on fire. S2 went onto the balcony, removed the oxygen tubing canula from R1’s nose, lifted R1 up, and carried them out of the apartment to safety.

S2 stated that they called 911 at 7:07 AM and that the fire department arrived approximately ten minutes later. S2 stated that R1 uses an oxygen concentrator at all times. S2 stated that staff did not supply oxygen to R1 from the time she was evacuated from her apartment until the fire department arrived on scene. S1 stated that R1 was transported to the local hospital for smoke inhalation.

(Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2025
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: 08/29/2025
NARRATIVE
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The LPA inspected R1’s apartment. LPA Lindstrom observed the outlet in the living room where the fire started. The counter wall with the outlet had black scorch marks on it, as did the adjacent carpeting and wall. LPA Lindstrom observed a thin, blackened line that ran from the outlet area, across the living room carpet, under the balcony door, and across the balcony floor, to within approximately ten inches of the chair R1 had been sitting in. LPA Lindstrom observed charred remains of oxygen concentrator tubing on the balcony floor. The LPA also observed the uncharred remains of tubing, including the cannula, and approximately two and half feet of line coming from it.

LPA Lindstrom observed a photograph of damaged items removed from R1’s room. The damaged items included a rectangular device approximately 3 feet wide by 2 feet deep. S1 stated that they had never noticed the electric fireplace in R1's apartment. S2 stated that the electric fireplace had been in the resident’s room since Fall 2023 when the resident moved in. S3 stated that she had observed the electric fireplace in R1’s room since early 2024. On the day of the fire, the electric fireplace and the oxygen concentrator had been plugged into a non-surge protected outlet extender located at the outlet where the fire started.

LPA Lindstrom reviewed the facility’s Admission Agreement, titled “Foothill Village California Residency Agreement.” R1 signed this agreement on 9/20/2023. This admission agreement was written by Integral Senior Living, which was the previous management company for the facility. In May 2025, Red Bench Living assumed management of Foothill Village. The LPA observed that on page 6 of the admission agreement that R1 signed, there is a section titled “Explosives, Firearms, and Flammables.” This section says: “No explosives, flammable materials, or firearms may be brought into any area of the community. This includes weapons, barbecue equipment, gasoline, motor oil, space heaters, and candles.”

LPA Lindstrom reviewed the facility’s LIC610E Emergency and Disaster Plan for Residential Care Facilities for the Elderly. The LPA reviewed Section C of page 6, which lists procedures that address, “Operating assistive medical devices that need electric power for operation, including but, not limited to oxygen equipment…” The facility made no mention of plans for assistive oxygen equipment on the form. S2 stated that facility staff did not administer oxygen to R1 between the time of evacuation from their apartment and arrival of the fire department.

(Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
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: 08/29/2025
NARRATIVE
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California Code of Regulations (CCR), Title 22, Section 87468.1(a)(2) states that residents shall have the personal right “to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.”

California Code of Regulations (CCR), Title 22, Section 87405(b) states that the facility administrator “shall have the responsibility and authority to carry out the policies of the licensee.”

California Code of Regulations (CCR) Title 22, Section 87212(b)(2)(A) states that “each facility shall have a disaster and mass casualty plan of action…” that includes a fire safety plan.

This facility is hereby cited per 22 CCR Section 87468.1(a)(2), Section 87405(b), and Section 87212(b)(2)(A). Due to a violation involving administrator qualifications and duties, an immediate civil penalty of five hundred dollars ($500) was hereby assessed. The immediate civil penalty was assessed using the LIC412IM paper form. The Administrator and Licensee were informed that a civil penalty assessment based on Health and Safety Code Section 1569.49(f) is currently under review and may be assessed at a later date. Once this has been determined, CCLD personnel will return to assess the civil penalty, if necessary.

An exit interview was held with the Administrator. Appeal rights and a copy of this report were left with the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/29/2025 05:50 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Ellen Lindstrom On 08/29/2025 at 04:03 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/05/2025
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights (2) To be accorded safe, healthful and comfortable accomodations, furnishings and equipment. This requirement was not met as evidenced by::
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Licensee will conduct inspections of all resident rooms to ensure all non-surge protected multi-plut outlet extenders are removed from resident rooms.
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The facility failed to remove the non-surge protector multi-plug outlet extender that caught on fire.
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Under Appeal
Type A
09/05/2025
Section Cited
CCR87405(b)

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Administrator-Qualifications and Duties
(b) The administrator of a facility shall have the responsibility and authority to carry out the policies of the licensee.

This requirement is not met as evidenced by:
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Licensee will conduct inspections of all resident rooms to ensure all space heaters are removed from resident rooms.
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Based on the admissions agreement stating that space heaters are not allowed and the facility allowed resident to have a fireplace space heater.
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/29/2025 05:50 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Ellen Lindstrom On 08/29/2025 at 04:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/05/2025
Section Cited
CCR
87212(b)(2)(A)

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Emergency Disaster Plan
(b)...The plan...include (2) Plan for evacuation including: (A) Fire safety plan.
This requirement was not met as evidenced by:
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Licensee will develop an emergency disaster plan that includes procedures for assistive medical devices for oxygen equipment.
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Section C on page 6 of LIC610 did not include mention of oxygen equipment.
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


LIC809 (FAS) - (06/04)
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