Holy Hill Inc./Carfax Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Rachel Duque and explained the purpose for today’s visit, shortly after Administrator Robert arrived to assist with visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and above. The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms, 2 full bathrooms, living room, kitchen, dining area, laundry area, den, detached garage with office and tool shed used as storage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: Facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (Continued on LIC809-C) Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff has criminal record clearance, current First-Aid/CPR/AED training along with other ongoing training are documented in personnel files. LPA reviewed 5 staff files and observed 2 staff missing their valid First-Aid certificates missing from file, citation will be issued and detailed on the LIC809-D. Administrator Teresa Santos certificate expires on 8/20/2027. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 3 Resident Files and observed that Resident #1 was missing their Physician's Report, citation will be issued and detailed on the LIC809-D. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 2 residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 9/2/25. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, there deficiencies observed during the visit will be documented on the LIC809-D page. Exit interview held, a copy of the report and appeal rights were emailed to Robert Francisco.the state’s words, verbatim · CDSS document, Sep 29, 2025

Allegation investigated: Resident sustained unexplained bruising.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator Robert Francisco and the purspose of the visit was discussed. During todays visit, LPA interviewed residents #1-#4 (R1-R4) and Staff #1-#3 (S1-S3). LPA conducted a health and safety check of the home, LPA reviewed and collected documents from R1's file related to the investigation. The investigation revealed the following: In regards to the allegation "Resident sustained unexplained bruising", it is alleged that R1 had multiple unexplainable bruises on their body. (3) of (3) Staff interviewed denied the allegation. (4) of (4) Clients interviewed could not corroborate the allegation.... Continued on LIC 9099-C Unsubstantiated Interviews show that R1 has an underlying health condition as well as a combination of medications that may lead to bruising easily so staff do body checks for R1. Staff stated any observations of bruises would be noted in the facilities communication logs as well. On 12/28/24 facility staff noticed bruising on R1's face and arm. R1 was unable to explain the bruising and staff had not observed any falls or accidents; therefore, resident was transported to the hospital for evaluation. Resident returned the same day with summary that the bruising may have been a result of their health condition. R1 interview was attempted but R1 was unable to respond to questions from LPA. Residents interviewed stated they have no issues or concerns and they feel safe in the facility. LPA observed various notes in R1's file, one from a nurse visit and one from the primary physicians stating that resident bruising to be normal/common/easily bruised due to their health condition and medication list. LPA observed the facilities communication log confirming that staff conducted a check on R1 and observed the bruising. LPA did not observe any immediate health and safety concerns during the visit. Based on file reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 28-AS-20250107092140

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Tiffany Kim and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and above. The facility currently has 3 Residents all of which are serviced through Harbor Regional Center. The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms, 2 full bathrooms, living room, kitchen, dining area, laundry area, den, detached garage with office and tool shed used as storage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and there is an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. (Continued on LIC809-C) Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Tiffany Kim certificate expires on 3/7/2025. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 2 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 2 residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 6/8/2024. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Tiffany Kim.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted the required-1 year inspection. LPA was allowed entry by Loida Carlos, Caregiver and explained the purpose of today's visit. Administrator, Edgardo Francisco arrived at 11:00am and assisted with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 6/25/2024. Surety bond (Western Surety) of $2,000.00 is current and will expire on 03/04/2026. The last fire and emergency drill was conducted on 10/05/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over. Current census is four (4), of which three (3) are non ambulatory and one (1) ambulatory. Facility is being serviced by Harbor Regional Center. Home consists of four (4) resident bedrooms, 2 bathrooms, living room, dining room, family room, kitchen, backyard, and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has (2) fire extinguishers in the facility. One (1) fire extinguisher located in the kitchen was purchased on 6/08/2023. The other (1) fire extinguisher located in the bedroom hallway was purchased today, 11/30/2023. Both bathrooms toured were observed to be fully stocked with hand soap, and paper towels, and had the required grab bars and nonskid mats in place. All showers in bathrooms accommodate non-ambulatory clients. However, LPA observed an all purpose cleaner bottle stored in an unlocked cabinet under the sink in bathroom #1. In bathroom #2, LPA observed mold and mildew in the shower area. At 10:50am, hot water temperature readings measured 112.2 deg F in the kitchen, 111.9 deg F in bathroom #1 and 109.7 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit. Medication was observed to be centrally stored in the kitchen cabinet. ***CONTINUED ON LIC 809-C** Staffing: A total of thirteen (13) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate is valid and will expire on 03/07/2025. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Resident Records-Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. Resident Rights-Information: Resident personal rights are posted. Physician order for use of 1/2 half bed rail was reviewed in (1) resident's files. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Four (4) residents attend the Day Program 2x-5x a week. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. All sharps were observed to be stored in a kitchen cabinet, which has a locked door. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Not currently, but Home Health personnel serviced one (1) of the residents in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis for all staff and residents. Residents with Special Health Needs: None of the residents are receiving home health services. Postural support physician orders are on file. Half bed rail for mobility assistance was observed in one resident in bedroom #1. Individual Service Plans and Appraisals for residents are on file. No residents have prohibited health conditions. Deficiencies were cited, Technical Assistance was issued, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Edgardo Francisco.the state’s words, verbatim · CDSS document, Nov 30, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.