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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607211
Report Date: 10/26/2024
Date Signed: 10/26/2024 05:01:37 PM

Document Has Been Signed on 10/26/2024 05:01 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/
DIRECTOR:		MARICIEL GAMBOAFACILITY TYPE:
740
ADDRESS:1025 LEANDRA LANETELEPHONE:
(626) 802-5613
CITY:ARCADIASTATE: CAZIP CODE:
91006
CAPACITY: 6CENSUS: 4DATE:
10/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Mariciel Gamboa, administratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Mariciel Gamboa, Administrator and explained the purpose of the visit. The facility has a capacity of six (6) residents and is licensed to serve elderly residents age 60 and above. The facility was approved for six (6) non-ambulatory residents which may retain four (4) hospice residents. Facility have 24 hour awake staff. Currently, all four (4) residents are non-ambulatory. Annual fees are current.

Today's visit, CARE tool was used, a tour of the facility was conducted, medication/facility files were reviewed, staff/residents/food supplies were interviewed.

The facility is a single family home, located in a residential area, consisted of living room, dining area, attached garage/storage, kitchen, pantry, TV room, three (3) resident bedrooms, two (2) bathrooms and staff office/lounge room. All rooms were furnished with required furniture. 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 117.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. 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. Fire extinguisher was mounted in the kitchen wall and fully charged. 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.

Deficiency was observed and cited in LIC 809D.

An exit interview was conducted. LIC 809s report were discussed and provided to facility Administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2024
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 10/26/2024 05:01 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/26/2024 at 04:02 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: 10/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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A knife was stored in a drawer (with no lock) in the kitchen and accessible to residents. Dish detergents were stored in the cabinet (with no lock) under the sink and accessible to residents.
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: 10/29/2024
Plan of Correction
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Licensee agreed to lock the sharp items and cleaning solutions making them unaccessible to residents. Licensee will provide in-service training to staff regarding Title 22, section 87309(a) by the POC date. Licensee will email the training sign- in sheet to proof the trainging was provided.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2024


LIC809 (FAS) - (06/04)
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