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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006352
Report Date: 09/15/2026
Date Signed: 09/15/2026 10:44:35 AM

Document Has Been Signed on 09/15/2026 10:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLS OF HAYWARD, THEFACILITY NUMBER:
306006352
ADMINISTRATOR/
DIRECTOR:		NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:835 S HAYWARD STREETTELEPHONE:
(714) 827-1016
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 2DATE:
09/15/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Spoke with Licensee (LE) Allen Medina via phoneTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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LIcensing Program Analyst (LPA) Rose Ruppert arrived unannounced to conduct a Case Management visit. LPA was greeted and granted entry by Staff at 8am and spoke with Licensee (LE) Allen Medina via phone. LPA explained the purpose of the visit and was with LPA Jerome Haley, who was conducting a complaint investigation.

During the visit, LPA delivered findings for two open complaints with the Department. Due to technical issues, the deficiency for the substantiated complaint that the facility did not have electricity, has been added to this Case Management report with a $1000 Civil Penalty for a Repeat violation from August 20. 2026.

LPA toured the facility which was 76 degrees Fahrenheit. The facility had two days of perishable items and seven days of non-perishable food on hand. Knives and chemicals were secured and facility bathrooms were sanitary and there were no odors detected. Utilities were operational and there was one staff member caring for two residents. LPAs Ruppert and Haley observed in Bedroom #1 that a bed was blocking the fire cleared exit. A deficiency will be cited. LPAs Ruppert and Haley also observed there was a camera, with visual and audio, for the resident in Bedroom #1. A deficiency for personal rights has also been cited. LPA toured two of two residents regarding the quality of care and one staff member regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Licensee, Allen Medina via phone with permission for staff to sign the report. A copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.
Alisa Ortiz
RoseMarie Ruppert
DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/15/2026 10:44 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 09/15/2026 at 09:45 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF HAYWARD, THE
FACILITY NUMBER: 306006352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2026
Section Cited
CCR
87303(a)

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(a) 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 was not met as evidenced by: Based on LPA interviews
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Licensees (LE) immediately restored facility electricity on the day of the incident, July 9, 2026. Electricity bills have been requested by the Department for July and August. Licensees will email LPA by POC due date.
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(cont'd) and observations, the facility did not have electricity for all staff and residents in care. This poses an immediate health and safety risk for staff and residents in the facility.
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Type A
09/16/2026
Section Cited
CCR87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement was not met as evidenced by: LPA observed bedroom #1 had a bed blocking the exit. This poses an
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Licensee will remove the second bed blocking the fire exit by POC due date. LE will text LPA a picture of the cleared exit.
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(Cont'd) immediate health and safety risk for one of one residents in care.
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2026 10:44 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 09/15/2026 at 10:14 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF HAYWARD, THE
FACILITY NUMBER: 306006352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2026
Section Cited
CCR
87468.1(a)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: LPAs Ruppert
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Licensee will follow-up with the family. Family will submit documentation stating they wanted cameras and were the ones who placrd the cameras. Licensee will email by POC due date.
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(cont'd) and Haley observed a video camera with audio in one of one resident's room. This poses an immediate personal right's risk for one of one resident in care.
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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