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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 03/14/2023
Date Signed: 03/14/2023 02:27:38 PM


Document Has Been Signed on 03/14/2023 02:27 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: 44DATE:
03/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
02:10 PM
NARRATIVE
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On 03/14/23 at 1:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit and met with executive director (ED) and discussed the following deficiencies observed during the 03/07/23 pre-licensing inspection:
  • Medication room small refrigerator lock broken; Medication room cabinet doors to be repaired for proper closure
  • Lack of covered trash bins available in each residents' bedroom; lack of paper towel dispensers in each residents' bathroom; lack of operating carbon monoxide detectors on 1st & 2nd floors


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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 03/14/2023 02:27 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: 03/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited

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The facility shall be clean, safe, sanitary and in good repair at all times.
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Deficiency corrected on 3/14/23.
Broken small refrigerator lock was replaced and med room cabinet door was repaired.
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This requirement was not met as evidenced by broken refrigerator lock, broken med room cabinet door which posed a potential health & safety risk to residents in care.
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Type B
03/14/2023
Section Cited

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The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment
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Deficiency corrected on 03/14/23.
ED purchased 5 new carbon monoxide detectors & installed them in the 1st & 2nd floors. ED also purchased new covered trash bins and paper towel holders for residents' rooms.
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This requirement was not met as evidenced by lack of covered trash bins, paper towels and carbon monoxide detectors which posed a potential health & safety risk to residents 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2