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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 01/20/2023
Date Signed: 01/20/2023 05:03:49 PM


Document Has Been Signed on 01/20/2023 05:03 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:BROUSSARD, EUGENIE MFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 40DATE:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Eugenie Broussard, Administrator
Crystal Sheenhan, Resident Care Coordinator		TIME COMPLETED:
05:18 PM
NARRATIVE
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On 1/20/2023 at 4:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Resident Care Coordinator, Crystal Sheenhan.

While LPA was conducting a complaint investigation, the following deficiency was observed.


LPA observed facility had incomplete files for staff. LPA was informed that vaccination records were not available for review.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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 01/20/2023 05:03 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited

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Personnel Records. All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidence by:
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Facility has agreed to create a written plan to have all staff records available for future reviews and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having staff's vaccination records available which poses a potential health and safety risk to the persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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