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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173007838
Report Date: 03/10/2020
Date Signed: 03/10/2020 12:17:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HILLCREST HOUSE, THEFACILITY NUMBER:
173007838
ADMINISTRATOR:WHITSON, DIANEFACILITY TYPE:
830
ADDRESS:15035 HILLCREST AVENUETELEPHONE:
(707) 995-3276
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:14CENSUS: 11DATE:
03/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Laura Hickey, Lead TeacherTIME COMPLETED:
12:35 PM
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An unannounced inspection was conducted by Licensing Program Analyst (LPA) N. Cunningham for the purpose of confirming the removal of an excluded individual, Saffron Blue (Staff 1). LPA met with the Lead Teacher, who stated Staff 1 never worked or volunteered at the facility. The Lead Teacher confirmed that they are aware that Staff 1 is not permitted to be in the facility at any time when children are in care. LPA toured the entire facility, and the excluded individual was not present.

Based on evidence obtained during today's visit, LPA has verified that the individual is not present, employed, or residing at the facility. The Lead Teacher understands and is aware that an immediate $500 Civil Penalty will be assessed for having any adults work or live in the facility without background clearance. The Enrollment Manager provided Confirmation of Removal LIC 300D to LPA. Verification of removal is complete. This report was reviewed and discussed with the Lead Teacher. All Licensing reports are public information, and must be made available upon request for at least three years.
Notice of Site Visit shall be posted for 30 days from today's inspection.

There were no Title 22 deficiency cited during today's inspection.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020
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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