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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200235
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:32:08 PM

Document Has Been Signed on 09/16/2022 01:32 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BUENAVISTA HOME AT HILLCRESTFACILITY NUMBER:
079200235
ADMINISTRATOR:RONALDO PEREZFACILITY TYPE:
735
ADDRESS:5517 SUNVIEW WAYTELEPHONE:
(925) 777-3880
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ronaldo Perez, Administrator
Glenn Sigue, Staff		TIME COMPLETED:
01:40 PM
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On 9/16/22 at 12:15PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an infection control inspection. LPA met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on his behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM. LPA observed 3 staff wearing face masks assisting clients with their lunch meals while the other 4 clients were resting inside their bedrooms.

LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs and medications stored in cabinets that are locked. Facility has an infection control plan and maintains records of routine screening for clients and staff. The infection control leader is the administrator.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/19/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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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