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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408194
Report Date: 11/07/2022
Date Signed: 11/07/2022 02:02:41 PM

Document Has Been Signed on 11/07/2022 02:02 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HILLCREST COTTAGEFACILITY NUMBER:
336408194
ADMINISTRATOR:NOEMI MAMANIFACILITY TYPE:
740
ADDRESS:1087 HILLCREST CTTELEPHONE:
(909) 795-5748
CITY:CALIMESASTATE: CAZIP CODE:
92320
CAPACITY: 6CENSUS: 4DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Edith Sepulveda Support Staff TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Bernadette Allen identified herself to the Edith Sepulveda- Support Staff who was informed of the purpose of the visit.

During the inspection, LPA Allen interviewed Edith Sepulveda regarding the facility's infection control measures and inspected the facility for regulatory compliance. There is a Mitigation Plan (LIC808) on file.

Edith Sepulveda stated that the facility does not currently have a COVID-19 cases.

LPA Allen observed appropriate postings in the facility, including personal rights and visitation policies, which were in accordance with the Department's guidelines. LPA Allen observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Allen observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA Allen observed that the facility appeared to be meeting operational requirements. LPA Allen observed that all utilities and appliances were functioning properly, and all passageways clear of obstruction, including emergency exits.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HILLCREST COTTAGE
FACILITY NUMBER: 336408194
VISIT DATE: 11/07/2022
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The facility was equipped with sufficient food supply and emergency supplies. All inspected areas of the facility, including client’s bedrooms and restrooms, appeared clean and in good repair. LPA Allen observed no apparent health and safety risks at the time of visit.

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed, and a copy of this report was provided to Edith Sepulveda at the conclusion of the inspection

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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