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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 10/10/2022
Date Signed: 10/10/2022 04:35:55 PM


Document Has Been Signed on 10/10/2022 04:35 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: 39DATE:
10/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Donna, Bautista- Colmenares, Executive DirectorTIME COMPLETED:
04:45 PM
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On 10/10/22 at 12:57 PM, Licensing Program Analysts (LPA) Jill Clancy-Czuleger conducted a Health and Safety check as a result of the department receiving a priority 2 complaint.

During the health and safety check, LPA observed a total of 8 staff wearing face masks and 39 residents at the facility. LPA toured facility with staff (S1), including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and were engaged in conversations with staff.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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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