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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603825
Report Date: 09/18/2023
Date Signed: 09/18/2023 11:32:03 AM

Document Has Been Signed on 09/18/2023 11:32 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S FOOTHILL VILLAFACILITY NUMBER:
374603825
ADMINISTRATOR:KELLY WELKERFACILITY TYPE:
740
ADDRESS:1152 SAL LANETELEPHONE:
(760) 295-3523
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 5DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Garrett Welker, AdministratorTIME COMPLETED:
11:27 AM
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Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:34 a.m. to conduct an unannounced annual visit. LPA met Caregiver Clara Castro at the front door and was granted entry. The Administrator Garrett Welker joined at 11:00 a.m. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for 6 non-ambulatory and 1 bedridden resident with 5 non-ambulatory residents in care. The facility has an approved hospice waiver for 3 residents.
Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of 6 resident bedrooms, and 3 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 116 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the across from the kitchen and inaccessible to residents. The ARF and has a current fire clearance for the facility, smoke and carbon monoxide detectors are in working order.
Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings, including but not limited to Dementia Care, Elderly Abuse, food preparation, and cleaning and emptying a catheter.

(Continued on LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S FOOTHILL VILLA
FACILITY NUMBER: 374603825
VISIT DATE: 09/18/2023
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(Continued from LIC809)

Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, hospice documentation, IPP, ISP, client rights,and admissions agreement.
Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook for PRN medication and the facility is in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 08/10/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator Garrett Welker and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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