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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601310
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:16:25 AM

Document Has Been Signed on 05/06/2022 11:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIDDEN MEADOWS RESIDENTIAL HOME CAREFACILITY NUMBER:
374601310
ADMINISTRATOR:MONINA ARJONAFACILITY TYPE:
740
ADDRESS:27806 DOGWOOD GLENTELEPHONE:
(760) 751-8575
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 4DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Monina Arjona, AdministratorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA), Chinwe Nwogene and Licensing Program manager (LPM), Deborah Mullen made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Leonida Dejesus., who was informed of the purpose of the visit. Leonida called the Administrator Monina who arrived at the facility shortly. At the time of visit there was 2 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases. LPA did not observe any pools or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual fees due.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms (3 restrooms.)

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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
RIVERSIDE, CA 92507
FACILITY NAME: HIDDEN MEADOWS RESIDENTIAL HOME CARE
FACILITY NUMBER: 374601310
VISIT DATE: 05/06/2022
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The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to the Administrator Monina Arjona

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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