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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005625
Report Date: 09/05/2024
Date Signed: 09/05/2024 12:34:05 PM

Document Has Been Signed on 09/05/2024 12:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILL MANOR ELDERLY CAREFACILITY NUMBER:
306005625
ADMINISTRATOR/
DIRECTOR:		MIRABUENO, MARIA PRICILLAFACILITY TYPE:
740
ADDRESS:13021 HEWES AVENUETELEPHONE:
(714) 516-9116
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Maria MirabuenoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. Staff contacted Administrator Maria Mirabueno and informed her of the visit. Maria Mirabueno's Administrator's Certificate expires on November 1, 2024. Facility is a one story home with 5 bedrooms (1 is for staff), 3 bathrooms, dining room, eat in kitchen, living room and a detached 2 car garage. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry of the facility. LPA and staff toured the facility. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. Knives are kept locked in a kitchen drawer. Medication is kept locked in a kitchen cabinet. LPA observed the 5 burner cook-top lights unassisted. LPA and staff toured the resident rooms. LPA observed the resident rooms had the required furnishings. LPA observed the hall closet is kept locked and used for storage of supplies. LPA observed all 3 bathrooms were clean and operational. Hot water measured 130.0 degrees Fahrenheit in bathroom 1. LPA and staff toured the backyard and the garage. The garage is used for storage and kept locked. LPA observed extra supplies and furniture stored in the garage. There are 2 sheds in the garage. Both sheds are kept locked and used for storage. LPA observed old furniture and tools are kept in both sheds. No bodies of water observed There are 3 exit gates in the backyard. All exit gates are operational. The Administrator arrived during the visit. LPA reviewed 5 resident files and 5 resident medications. No discrepancies observed. LPA reviewed 2 staff files. Both staff members had CPR training and the required annual training. No discrepancies observed. Both staff members are background cleared and associated to the facility. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA consulted with the Administrator concerning reporting requirements and resident rights. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 09/05/2024 12:34 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 09/05/2024 at 12:21 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILL MANOR ELDERLY CARE
FACILITY NUMBER: 306005625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in, LPA measured the hot water in bathroom 1 at 130.0 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Licensee will adjust the hot water to measure within regulatory requirements and keep a weekly water temperature log to ensure the proper water temperature is always maintained at the facility.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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