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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:54:02 PM


Document Has Been Signed on 09/07/2022 03:54 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:DONNA BAUTISTA- COLMENARESFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 43DATE:
09/07/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Donna Bautista-Colmenares, Executive Director
Dinesh Sawhney, Licensee
Joel Goldman, Legal Consultant		TIME COMPLETED:
03:15 PM
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An Informal Conference was held on this day, September 7, 2022 via video conference. The purpose of this conference was to discuss non-compliance issues. The informal conference process was explained to the licensee and administrator. Licensee and administrator were informed that this Informal Conference is part of the administrative action process and that further citations will result in a formal Non-Compliance Plan and referral to the Department's Legal Division for possible formal Administrative Action.

Present at the meeting were:
1. Licensing Program Manager (LPM) Jeremy Fong
2. Licensing Program Analyst (LPA) Daisy Panlilio
3. Donna Bautista-Colmenares/Executive Director
4. Dinesh Sawhney/Licensee
5. Joel Goldman/Legal Consultant

Issues discussed during the meeting:
-Resident eloped from facility
-Staff sleeping during shift

A corrective measure was taken by Executive Director with new staff hired and trained in caring for persons with Dementia. Ongoing quarterly training per shift is conducted by Executive Director to ensure staff is fully trained in dementia care and supervision.

At the conclusion of this informal conference, Executive Director was informed that the facility has to maintain compliance.

Exit interview conducted and copy of this report provided to the Executive Director via e-mail.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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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