197608283-12-7-2023-29-AS-BBAI-CYAUQQ-20231207144731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608283
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:48:51 PM

Document Has Been Signed on 12/07/2023 02:48 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILLTOP HAVEN 2		FACILITY NUMBER:	197608283
ADMINISTRATOR:	ERWIN DUFFELS		FACILITY TYPE:	740
ADDRESS:	6531 GLORIA AVENUE		TELEPHONE:	(818) 474-9671
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 5	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Erwin Duffels		TIME COMPLETED:	03:00 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 10am. Upon arrival LPA met with Staff and explained the reason for the visit. Shortly after Administrator Edward Duffels and Caregiver Tom Stiles arrived. At approximately 09:00am, tour of the physical plant was conducted with Stiles and Duffels. Facility has (4) resident bedrooms and a staff room. (2) of the bedrooms are private resident rooms. Hallway bathroom is designated for common use. All resident rooms have a private bathroom, with the exception of resident room 4. LPA toured the facility with Stiles. The kitchen appeared to be relatively clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer in the office area on the left side of the kitchen. LPA observed drawer to be locked at this time. Laundry area was located next to the kitchen. Cleaning products were observed to be inaccessible to residents in care at this time. The fire extinguishers were fully charged and last purchased on 11/17/2023. There is a dedicated area for the posting of required documents located in the office area in the kitchen. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture appeared to be relatively clean and functional at this time. At 9:30am, LPA observed (2) residents eating breakfast.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLTOP HAVEN 2	FACILITY NUMBER: 197608283
	VISIT DATE: 12/07/2023

NARRATIVE

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The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed (5) bedrooms that includes a staff room. Staff room was observed to be inaccessible to clients in care and empty at the of the visit. Extra linen is kept in a cabinet in the hallway. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet nearest to common bathroom.

All bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured between 105 and 120 degrees Fahrenheit. There is enough clean linen available in stock at the linen cabinet.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There is an above ground drained spa enclosed and locked inaccessible to residents in care. LPA observed a sufficient amount of space for activities. LPA did not observe any obstructions to emergency exit at this time. The backyard and exterior area of the facility is completely fenced with a self-latching gate at the facility entrance. At approx. 09:45am, LPA observed at the rear of the facility is a detached garage and an Adult Dwelling Unit with three (3) units, where caregivers Tom and Cathy reside. The landlord resides in the middle unit. Each unit was observed to be empty at the time of the visit. This area is separated by a fence. The detached garage was observed to be inaccessible to residents at this time. In the garage, LPA observed a boat, furniture and multiple household items.

Records review began at approx. 09:45am, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. three (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be in order at this time.

Medications review began at approximately 11 a.m. The medications are centrally stored in the medication cabinet closet near the laundry. Medications are properly documented on the centrally stored medications and destruction record.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLTOP HAVEN 2	FACILITY NUMBER: 197608283
	VISIT DATE: 12/07/2023

NARRATIVE

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SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLTOP HAVEN 2	FACILITY NUMBER: 197608283
	VISIT DATE: 12/07/2023

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Continued from 809-C
Between 1pm - 2pm , LPA interviewed three (3) residents and three (3) staff.

The LPA spoke with Tom regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate room #4 as a single isolation room if the facility has a confirmed case of a communicable disease. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

During the physical plant LPA observed the physical plant was not consistent with the submitted facility sketch/floor plan when this facility was initially licensed, as the sketch indicates there are (2) separate buildings in the rear of the lot, when there is actually (1) L shaped building split into three (3) units for two (2) of the caregivers and the landlord. An updated STD 850 will be provided to the Department.

During the visit, LPA obtained an updated Limited Liability insurance, Census and LIC 500

Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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