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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:25:03 PM


Document Has Been Signed on 03/03/2022 04:25 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 LIVINGFACILITY NUMBER:
079200389
ADMINISTRATOR:JARRETT SUELLFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 40DATE:
03/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eleina Ridolfi, Interim AdministratorTIME COMPLETED:
05:00 PM
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On 03/03/22 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety check and met with resident coordinator and interim administrator. LPA explained the purpose of the visit with resident coordinator and interim administrator.
During the health and safety check, LPA observed a total of 5 staff wearing face masks and 40 residents at the facility. Routine COVID symptom checks were performed at the front desk for visitors. LPA toured facility with resident coordinator, including but not limited to bedrooms, kitchen, bathroom, and common areas.

Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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