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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530050
Report Date: 10/13/2022
Date Signed: 10/13/2022 12:29:36 PM

Document Has Been Signed on 10/13/2022 12:29 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:HILLSIDE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
365530050
ADMINISTRATOR:RICHARDSON, STEPHANIEFACILITY TYPE:
740
ADDRESS:15027 MANNING STREETTELEPHONE:
(818) 259-9107
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 6CENSUS: 0DATE:
10/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Stephanie Richardson, LicenseeTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an announced visit to the facility to conduct a pre-licensing inspection for an initial application. LPA Nickolas met with Licensee Stephanie Richardson and explained the purpose of the visit.

The facility has been granted a fire clearance on 08/25/22 by Victorville Fire Department for a total capacity of six (6) clients; five (5) non-ambulatory clients and one (1) bedridden client.

The facility has a total of four (4) bedrooms, three (3) of which are clients'. The facility has two (2) and half (1/2) (2 1/2) bathrooms, two (2) of which are clients', a kitchen and dining area, a living room, activity areas, and backyard. LPA and licensee toured the interior and exterior of the facility. There is a shaded seating area for clients in the backyard. LPA observed that side gates were unlocked and free of obstruction. The facility had a working telephone for client use. The facility has charged fire extinguisher, smoke alarms, and carbon monoxide detectors. The facility had a complete first aid kit and manual. A locked centralized storage area for medications. The following were observed of the physical plant:

Client Bedrooms: LPA observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.
Client Bathrooms: LPA observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients.
Kitchen and Dining Area: LPA inspected the kitchen and found sharps were kept in a safe and secured place. Dishes, glasses, and utensils were in good condition and stored in a safe manner.
Common (living/activity) areas: LPA observed night lights were maintained in the hallways. There is adequate seating in the common areas. The facility had a supply of activities for the clients.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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 2
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: HILLSIDE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 365530050
VISIT DATE: 10/13/2022
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LPA observed that the physical plant is clean, in good repair, and appear to be hazard-free during today’s visit. LPA have determined that the facility is meeting operational requirements. LPA completed COMP III with the licensee at the conclusion of the inspection.

The pre-licensing inspection is complete, and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations (CCR).

An exit interview was conducted where this report was discussed, and a copy was provided to Stephanie Richardson at the conclusion of the inspection.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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