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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804165
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:50:08 PM

Document Has Been Signed on 12/04/2024 12:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HILL HOUSE, THEFACILITY NUMBER:
496804165
ADMINISTRATOR/
DIRECTOR:		LUGO SOTO, ROSA I.FACILITY TYPE:
740
ADDRESS:8840 EGG FARM LANETELEPHONE:
(707) 332-4494
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY: 6CENSUS: 5DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Rosa Soto, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Rosa Soto.

At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 113.5 and degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 3/26/24. Smoke/Carbon Monoxide detectors located throughout the facility are hard wired and last serviced by Santa Rosa Fire Equipment Inc on 9/18/24. Facility’s has not documented quarterly disaster drills, LPA discussed making sure they document the disaster drills and conduct them quarterly. Facility has sliding vertical locks on the doors and upstairs fire exit door had both a chain lock and vertical sliding lock. Facility immediately removed all vertical locks and chain lock from upstairs. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted review of 5 staff records. All required documentation present. LPA discussed training materials. Currently used training materials are videos from Community Care Options dated 2011. LPA discussed either updating training materials to something current and pertinent or using an approved vendor to conduct staff training. Facility will submit pictures of updated materials to CCL if an approved vendor is not chosen.


Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HILL HOUSE, THE
FACILITY NUMBER: 496804165
VISIT DATE: 12/04/2024
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Continued from 809...

At approximately 11:30am LPA conducted a review of 5 resident records. All required documentation present.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Centrally Stored Medication log not completed for R1 (deficiency cited, see 809D). LPA discussed pre-pouring medications. Admin advised that they pour in the morning for morning meds and pour in the afternoon for evening meds. Admin advised they never pre-pour medications the previous evening for the next day.

Rosa Soto Administrator Certificate 6006777740 expires 8/29/25.




Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 12:50 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/04/2024 at 12:26 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HILL HOUSE, THE
FACILITY NUMBER: 496804165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, interview, and record review, the licensee did not comply with the section cited above in that the licensee did not maintain a centrally stored medication for R1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying that a Centrally Stored Medication log has been completed for all residents by plan of correction 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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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