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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402904
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:42:11 PM

Document Has Been Signed on 04/13/2022 12:42 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:HOLY HILL HOME CAREFACILITY NUMBER:
366402904
ADMINISTRATOR:PURACI, LIVIUS & MARIAFACILITY TYPE:
740
ADDRESS:33922 COLORADO ST.TELEPHONE:
(909) 795-5575
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 6CENSUS: 4DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Maria and Livius PuraciTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 04/13/2022 at 09:55 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrators Maria and Livius Puraci and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrators Maria and Livius Puraci and they reported that Mitigation Plan was submitted to Community Care Licensing Department (CCLD). LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility and observed that resident bathrooms have paper towels and hand soap. At around 10:30 AM, LPA Brown observed two (2) knives with measurement 4.25 ft and 9.5 ft located in an unlocked drawer in the kitchen and LPA Brown also noticed that the lock of the knife drawer in the kitchen is broken making all knives at the facility accessible to residents in care. LPA Brown requested Staff 3 to lock all knives in a locked drawer during the visit. LPA Brown will be issuing a deficiency as this poses an immediate risk to residents in care. In addition, LPA Brown observed evidenced of water leak in the hallway ceiling from the front door going to the kitchen and Licensee Livius Puraci reported that it was the facility's air conditioning unit that caused the leak. LPA Brown will be issuing a deficiency as this poses a potential risk to residents in care.

LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns, face shields/goggles. LPA Brown went over the various recommended training for facility staff with Administrators Maria and Livius Puraci in relation to COVID-19 and they both reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.


*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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Document Has Been Signed on 04/13/2022 12:42 PM - It Cannot Be Edited


Created By: Melody Brown On 04/13/2022 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HOLY HILL HOME CARE
FACILITY NUMBER: 366402904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having the facility in good repair due to the evidenced of water leak in the hallway ceiling from the front door going to the kitchen which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee stated that they will fix/repair the evidenced of water leak caused by the air conditioning unit of the facility located in the hallway ceiling from the front door going to the kitchen and submit proof of correction to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2022 12:42 PM - It Cannot Be Edited


Created By: Melody Brown On 04/13/2022 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HOLY HILL HOME CARE
FACILITY NUMBER: 366402904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120276


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of persons in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the Licensee did not verify, worker's vaccination, booster or exemption status as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Licensee stated that they will submit proof of staff 3 vaccination/Exemption and Booster Vaccination/Exemption for Staff 1 and Staff 2 to LPA Brown by POC due date and will also update staff file at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2022 12:42 PM - It Cannot Be Edited


Created By: Melody Brown On 04/13/2022 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HOLY HILL HOME CARE
FACILITY NUMBER: 366402904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having the knives accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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Licensee stated that they will lock all the knives at the faciity. The Licensee immediately locked-up the knives found during the visit. Licensee stated to submit Statement of Understanding for CCR 87309(a).
Licensee stated that they will train all staff in CCR 87309(a) and submit Training Log to LPA Brown by POC due date.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not locking all the knives at the facility due to the observed knife drawer lock broken during the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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Licensee stated that they will repair/fix the knife drawer lock by POC due date and submit proof of correction to LPA Brown.
Licensee stated that they will submit Statement of Understanding on CCR 87309(a)(1) to LPA Brown by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


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: HOLY HILL HOME CARE
FACILITY NUMBER: 366402904
VISIT DATE: 04/13/2022
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LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrators Maria and Livius Puraci informed LPA Brown that at this time staff have not been fit tested. LPA Brown will not be issuing a deficiency but Technical Assistance Advisory Notes will be issued during today's inspection for staff not being fit tested for N95 masks due to the facility not having COVID-19 positive staff and N95 masks needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, all residents and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed Administrators Puraci of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 04/13/2022 at 10:45 AM, LPA Brown observed no vaccination record for Staff 3 and no exemption on staff file. Also, Staff 1 and Staff 2 do not have their booster information or booster exemption on file at the facility. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Vaccination which can pose potential risk to residents in care. Moreover, LPA Brown observed Administrator Livius Puraci not wearing mask during the visit and LPA Brown will be issuing a Technical Assistance Advisory Notes for staff not wearing mask.


An exit interview was conducted with Administrators Maria and Luis Puraci and a copy of this report (LIC809), LIC 809-D's, LIC9102 AN Technical Assistance Advisory Notes and Appeal Rights were provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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