<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 12/27/2022
Date Signed: 12/27/2022 04:02:05 PM


Document Has Been Signed on 12/27/2022 04:02 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: 38DATE:
12/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Marina Peckham, Resident Care DirectorTIME COMPLETED:
04:15 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 12/27/2022 at 03:10 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced complaint visit. This is a case management as a result of complaint #15-AS-20200518161350. LPA met with Marina Peckham, Resident Care Director (S5) and explained the reason for the Case Management.

On the following dates below resident and personnel documents were requested and not provided to CCLD.

· 11/16/22, LPA met with S5 and requested the following documents to be submitted to CCLD via email or fax on or before 12/01/2022: Resident roster, Staff roster with contact information, Physician's orders/prescriptions, and Medication Administration Records (MAR) for a sample of eight (8) residents.

· 12/13/22, S5 sent an email stating he/she is unable to locate the documents.

· 12/13/22, LPA sent an email to S5 asking was he/she able to to locate any of the documents and LPA requested current staff roster and schedule, training log/record that shows which staff were trained and/or was up to date on May of 2020.

· 12/27/22, Physician's orders/prescriptions, and Medication Administration Records (MAR) for a sample of eight (8) residents were not provided to LPA or CCLD.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided to Marina Peckham, Resident Care Director.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/27/2022 04:02 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited

1
2
3
4
5
6
7
87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
This requirement was not met as evidence by:

1
2
3
4
5
6
7
Licensee agreed that he/she and Administrator(s) will review the cited regulations and submit self-certifications to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above by retaining resident records which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
01/06/2023
Section Cited

1
2
3
4
5
6
7
87412 Personnel Records (h) All personnel records shall be retained for at least three (3) years following termination of employment.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee agreed that he/she and Administrator(s) will review the cited regulations and submit self-certifications to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above by retaining personnel records which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2