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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006352
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:19:41 PM

Document Has Been Signed on 03/15/2024 12:19 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:
03/15/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Marciel NepomucenoTIME COMPLETED:
12:35 PM
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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.

At 11:50 a.m. LPA toured the facility and observed the following:

ยท The bed with pillows, linen, and blankets and staffs' personal belongings in the garage have been removed. Designated AD stated garage will solely be used for storage.

Component III: was conducted during this inspection, information provided about how to operate the facility within compliance and reporting requirements.

The facility is ready to be licensed. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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