<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607211
Report Date: 09/20/2021
Date Signed: 09/20/2021 05:50:30 PM

Document Has Been Signed on 09/20/2021 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HILLSIDE HOME FOR ELDERLYFACILITY NUMBER:
197607211
ADMINISTRATOR:MARICIEL GAMBOAFACILITY TYPE:
740
ADDRESS:1025 LEANDRA LANETELEPHONE:
(626) 802-5613
CITY:ARCADIASTATE: CAZIP CODE:
91006
CAPACITY: 6CENSUS: 0DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mariciel Gamboa, AdministratorTIME COMPLETED:
04:30 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
Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arriving at the facility, LPA met with Mariciel Gamboa (Administrator) and explained the purpose of the visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, and approved for six (6) non ambulatory residents. Facility may retain four (4) hospice residents. Facility will have 24 hour awake staff. Current, no resident is residing at the facility.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, and food supply was reviewed. Since no resident residing at the facility, no medication was reviewed.

The facility is located in a residential area. A physical tour was conducted. The facility is a single-story house includes: living room, dining area, attached garage/storage, kitchen, pantry, TV room, three (3) resident bedrooms, two (2) bathrooms. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 107.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature for residents.

Sufficient supply of perishable and nonperishable foods were observed. Smoke detectors and carbon monoxide detectors are operable. Smoke detectors in the hallway and bedrooms are hard wired. New fire extinguishers were purchased on August 2021 and are fully charged.

(-continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HILLSIDE HOME FOR ELDERLY
FACILITY NUMBER: 197607211
VISIT DATE: 09/20/2021
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
26
27
28
29
30
31
32
The first aid kit is fully stocked. All mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents.

Facility was renovated. No change on capacity and ambulatory status. On the initial application, there was a walk-in closet in the master room and a laundry room. A wall between a walk-in closet and laundry room was removed. That space was turned into a staff lounge. City of Arcadia granted the permit of the renovation. City inspector will visit the facility for an inspection on 9/21/21.

Administrator agreed of not admitting resident until the facility is cleared and has a fire clearance.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/20/2021 05:50 PM - It Cannot Be Edited


Created By: Bonnie Tao On 09/20/2021 at 04:57 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HILLSIDE HOME FOR ELDERLY
FACILITY NUMBER: 197607211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:
The facility shall be clean, safe, sanitary and in good repair at all times. Old furniture are stacked up in the backyard and sideyard. Backyard had an un-even pavement.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
1
2
3
4
Licensee will ensure that the old furniture in the backyard and sideyard be removed. The uneven pavement will be leveled and even. Licensee will submit proof of correction by the due date.
Type B
Section Cited
CCR
87305(a)


This requirement is not met as evidenced by:
Alterations to Existing Building or New Facilities Prior to construction or alterations, all facilities shall obtain a building permit.
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
1
2
3
4
LPA Tao observed an alteration to the physical in the family room as evidenced by a wall between a walk-in closet at the master room and laudry room was removed. Administrator did not notify Licensing. Administrator states she has City of Aracadia granted the permit for renovation. City will do a follow up visit on 9/21/21 regarding this renovation. Administrator will provide 1) the visit report /permit of this renovation, (2) updated facility sketch, (3) updated plan of operation, (4) updated application LIC 200 to Licensing by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3