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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004575
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:50:13 PM

Document Has Been Signed on 02/24/2022 02:50 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLSIDE VIEWFACILITY NUMBER:
306004575
ADMINISTRATOR:EMMANUEL DIZONFACILITY TYPE:
740
ADDRESS:22122 PADOVA STREETTELEPHONE:
(949) 279-1700
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Emmanuel Dizon TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff Daisyree and explained the reason for the visit today. LPA was screened and temperature checked before entering the facility. LPA observed a screening station equipped with a log book, temperature thermometer and hand sanitizer. Facility staff called Administrator (AD) Emmanuel Dizon so he could be present for the visit. Administrator (AD) Dizon arrived at the facility at 2:07pm and the annual inspection began. LPA observed all required postings on the wall throughout the facility. AD Dizon states he will have the See Something (Pub 475) poster enlarged. AD Dizon has a current administrators certificate that expires on 09/15/2023. There are five residents in care at the facility. Residents were relaxing and resting in their room and all appeared to be well taken care of. LPA began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and storage space. Bathrooms were clean, operational, and equipped with soap, sanitizer, and paper towels. Water temperature was measured at 117.1 degrees Fahrenheit in bathroom #1 and 114.9 degrees Fahrenheit in bathroom #2. The kitchen was clean and organized. All knives and sharp objects were locked in a drawer. Cleaning supplies and toxins are locked under the sink, The facility has a two day supply of perishable food items and seven days supply of nonperishable food items. The stove was clean and all burners were operational. There is a first aid kit equipped with all required items in the medication cabinet in the hallway. LPA observed extra linen in the hallway closets. LPA toured the backyard and it was clean and free of clutter. LPA observed an exit gate on the side of the house that was self closing and self latching. LPA observed a shaded visitation area in the backyard equipped with tables and chairs for the residents in care. Smoke detectors were tested and are operational.
No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to Administrator Emmanuel Dizon.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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