079200389-2-28-2022-15-AS-DPAO-CC3UKK-20220228143916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 02/28/2022
Date Signed: 02/28/2022 02:40:43 PM

Document Has Been Signed on 02/28/2022 02:40 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:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	CECILY PALMA		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 48	DATE:	02/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Cecily Palma, Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/28/22 at 1:20PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 5 staff wearing face masks during visit. Facility has a completed mitigation plan in place dated 01/11/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA also observed mass testing being conducted for all residents and staff during visit. Per administrator, next mass testing is scheduled on 03/03. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has visitation areas to encourage social distancing among residents. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HILLCREST MEMORY CARE LIVING	FACILITY NUMBER: 079200389
	VISIT DATE: 02/28/2022

NARRATIVE

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There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies and PPEs were observed stored in locked cabinets on the 1st & 2nd floors. Medications are locked inside the medication room. Facility room temperature was maintained at 74 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Infection control designated 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 03/01/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC809 (FAS) - (06/04)

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