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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530137
Report Date: 09/29/2023
Date Signed: 09/29/2023 11:36:44 AM

Document Has Been Signed on 09/29/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILLS OF HAMILTON, THEFACILITY NUMBER:
365530137
ADMINISTRATOR:RAMIREZ, SOPHIAFACILITY TYPE:
740
ADDRESS:10466 HAMILTON STREETTELEPHONE:
(714) 430-7672
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
09/29/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Sophia Ramirez, AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at The Hills of Hamilton for an announced visit to conduct the Pre-Licensing Inspection for Change of Ownership. LPA introduced self and stated purpose of the visit. LPA was greeted by Sophia Ramirez, Administrator and Marciel Nepomuceno and invited inside the facility. LPA signed in and was provided a space to set up and work, then provided a tour of the facility inside and out. LPA observed the following:

Application: The application is for Residential Care Facility for the Elderly (RCFE). Fire clearance has been granted for five, (5) non-ambulatory and one, (1) bedridden resident. Fire clearance was approved on 5/24/2023.

Buildings and Grounds: The home is composed four, (4) bedrooms, living room, dining room, kitchen, backyard, and attached garage. Interior pathways were unobstructed and free of clutter. Smoke, Fire and Carbon Monoxide alarms were tested and found operational - all hardwired to one another. Two, (2) Fire Extinguishers were observed fully charged and last inspected May 2023. The backyard included adequate seating and spacing for activities and shady seating for residents in care. Exterior pathways were clear and unobstructed. Pathway along the right side of the facility is to be used for exit as space permits. There are no pools or other bodies of water located on premises. Administrator and Licensee report there are no weapons or ammunition kept in the facility.

Resident Rooms - each room included regulated mattress, bed linens, storage, seating, intact window screens and sufficient lighting. Each room also included extra linens and adequate storage space. One room has an attached bathroom. Bathroom appliances in working order and housed adequate paper and hygiene supplies. Bathrooms were observed to have non-slip bath mats available. As well as secure cabinets to hold hygiene supplies. The water temperature was tested and measured within regulation.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HILLS OF HAMILTON, THE
FACILITY NUMBER: 365530137
VISIT DATE: 09/29/2023
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Activity supplies observed in various spaces. The facility maintains telephone and internet services. The washing machine and dryer were observed secure in attached garage in good condition.
Storage and Supplies: Medications will be stored inaccessible to residents in a secure cabinet in the kitchen. Also maintained in the cabinet was First aid kit, staff and resident files, disaster plans and various supplies. Cleaning supplies will be stored in secure cabinet under kitchen sink. Sharps designated secure drawer. Linens, personal hygiene supplies, and equipment observed are all in good condition and sufficient for approved census.

Food Service: Utensils, dishware and storage space are sufficient for the requested capacity. The refrigerator and pantry observed to have adequate supply of food for the number of residents in care. Food observed included milk, eggs, bread, fresh vegetables and fruits.

Forms: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, Resident Rights, Facility Sketch/Evacuation Plans in each room. Labor laws and licensing information. LPA audited 4 resident files and observed them to include all regulated documentation.

No deficiencies were observed during inspection. Care Tool utilized. LPA will inform the Centralized Applications Bureau the home is ready to be licensed. An exit interview was conducted. This report was reviewed, discussed then provided to Marciel Nepomuceno, Licensee
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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