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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:00:18 PM


Document Has Been Signed on 03/07/2023 02:00 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: 39DATE:
03/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Eugenie Broussard, Executive Director
Marina Peckham, Resident Care Coordinator		TIME COMPLETED:
02:10 PM
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On 03/07/23 at 12:40PM, Licensing Program Analyst (LPA) conducted an unannounced case management visit and met with executive director (ED) and resident care director (RCD). LPA explained the purpose of the visit with ED and RCD.

LPA discussed 2 incident reports dated 2/27/23 and 3/01/23 wherein resident (R1) displayed aggressive behaviors towards two residents (R2. R3) on 2 different occasions at the facility. ED stated R1 is high functioning, has dementia and is not conserved. ED stated that on 02/27/23 R2 was sent to the hospital for evaluation and was released back to the facility with no new diagnosis. On 03/01/23, R3 was sent to the hospital for treatment and has been transferred to a skilled nursing facility for rehabilitation. R3 has not returned back to the facility.

ED stated R1 was admitted into the facility on 04/09/2021 thru a letter of agreement from the hospital. However, ED stated R1 never paid for basic services (rent, care and supervision) since she was admitted at the facility. ED stated they have notified the Ombudsman regarding R1's aggressive behaviors and non-payment of basic services.

The Ombudsman has referred ED to work with the Deputy Conservator of Contra Costa County to assist in addressing R1's health and safety needs. ED stated staff closely monitors R1 and redirects her when needed.

At 1PM, LPA toured facility with ED, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during visit.
Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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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