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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880915
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:53:01 PM

Document Has Been Signed on 05/09/2024 02:53 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HICKORYWOOD CARE HOMEFACILITY NUMBER:
331880915
ADMINISTRATOR/
DIRECTOR:		CARLSON, DAVID JFACILITY TYPE:
740
ADDRESS:1650 HICKORYWOOD LANETELEPHONE:
(951) 795-1623
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: 2DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:David Carlson - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with licensee Emelinda Carlson and David Carlson, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and two (2) residents present. The facility is licensed for six (6) non-ambulatory residents. The facility has a hospice waiver for six residents. A dementia program is also on file. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards and contained outdoor furniture for residents in care. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to clients. The sharp and dangerous objects were observed to be locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Two resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HICKORYWOOD CARE HOME
FACILITY NUMBER: 331880915
VISIT DATE: 05/09/2024
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Resident medication was centrally stored and locked in a closet located in the hallway. LPA reviewed medications prescribed to the residents and found all medication listed on the Medication Administer Record (MAR) had all required labeling and signatures found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. Records review revealed last fire drill was conducted 04/01/2024 which met department requirements. LPA observed emergency supplies and first aid kit with all required items. Facility contains multiple charged fire extinguishers located throughout the facility/

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Licensee Carlson.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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