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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:33:18 PM


Document Has Been Signed on 12/14/2022 01:33 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:
12/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Marina Peckham, Resident Care DirectorTIME COMPLETED:
01:40 PM
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On 12/14/22 at 1:05PM, Licensing Program Analyst (LPA) J. 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 7 staff members wearing face masks and 39 residents at the facility. LPA toured facility with staff (S2), including but not limited to bedrooms, kitchen, bathroom, and common areas. LPA observed 12 residents lounging in the visitation/TV areas while other residents were inside their bedrooms resting. 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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