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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006352
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:38:38 PM

Document Has Been Signed on 03/08/2024 12:38 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:HILLS OF HAYWARD, THEFACILITY NUMBER:
306006352
ADMINISTRATOR:NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:835 S HAYWARD STREETTELEPHONE:
(714) 827-1016
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marciel NepomucenoTIME COMPLETED:
12:50 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Marciel Nepomuceno. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 4/24/2023.

Structure:
The facility is a one-story house with four client bedrooms, two full size bathrooms, one half bathroom, a living room, kitchen, dining room, enclosed patio, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the kitchen. There is a backyard with one designated exit gate on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the garage.

Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored in the pantry area. The first aid kit has all the required elements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF HAYWARD, THE
FACILITY NUMBER: 306006352
VISIT DATE: 03/08/2024
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
Resident & Staff Files:
Records will be kept in a locked cabinet.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged with service tag dated 10/11/2023.

Reading Material, Games, Equipment & Materials:
The facility has reading books, activity books, board games, and other recreational materials for resident use stored in the living room.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 12/07/2023. Special conditions noted, “Bedroom #1 for bedridden and bedroom door shall self-close at all times.”

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 108.3-113.5 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu is posted and visible.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 2 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF HAYWARD, THE
FACILITY NUMBER: 306006352
VISIT DATE: 03/08/2024
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
Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

Licensee to address the following corrections by 03/16/2024:

LPA observed a section of the garage to be sectioned off with wall dividers. The area contains a made bed with pillows, linen, and blankets and also contains staffs' personal belongings. Designated AD stated bed and belongings would be removed as garage is solely used for storage.

LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3