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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530137
Report Date: 11/19/2024
Date Signed: 11/19/2024 05:15:03 PM

Document Has Been Signed on 11/19/2024 05:15 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILLS OF HAMILTON, THEFACILITY NUMBER:
365530137
ADMINISTRATOR/
DIRECTOR:		SHANELLREY KNOWLESFACILITY TYPE:
740
ADDRESS:10466 HAMILTON STREETTELEPHONE:
(714) 430-7672
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:51 PM
MET WITH:Justin Duclayan, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analysts (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with Interim Administrator Justin Duclayan, and introduced self and stated purpose of the visit. LPA was informed that there was 4 client in the home.

The facility has 4 bedrooms, 2 bathrooms, 1 staff bedroom, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPA completed a walk through of facility, review of records, and medication.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.4, 104.0 and 112.6 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 6/14/2024. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure and inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed secure and inaccessible to clients. The facility did have emergency kits in the facility for clients in care. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HILLS OF HAMILTON, THE
FACILITY NUMBER: 365530137
VISIT DATE: 11/19/2024
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Record Review: LPA reviewed two (2) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

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

An exit interview was conducted, and this report LIC809, and LIC809C, were discussed and provided to Facility Interim Administrator Justin Duclayan.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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