079201249-3-7-2023-15-AS-DPAO-CPQ2FW-20230307162214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201249
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:22:22 PM

Document Has Been Signed on 03/07/2023 04:22 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		FACILITY NUMBER:	079201249
ADMINISTRATOR:	FOZ, ROMERICO		FACILITY TYPE:	740
ADDRESS:	825 E 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 44	DATE:	03/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Eugenie Broussard, Executive Director Marina Peckham, Resident Care Director		TIME COMPLETED:	03:40 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 03/07/23 at 2:15pm, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced pre-licensing inspection (facility is in operation and changing ownership). LPA met with executive director (ED) and resident care director (RCD). LPA explained the purpose of the visit. The facility has an approved fire safety clearance for total capacity of ninety (90) residents dated 01/12/23. LPA inspected the facility inside and out including but not limited to the medication room, bedrooms, bathrooms, common living areas, kitchen and backyard. The facility has 2 floors with 15 residents residing in private apartments with full bathrooms on the second floor and 29 residents living in their private apartments with full bathrooms on the first floor. Sufficient PPEs, disinfectants and paper supplies were observed stored in locked cabinets & rooms on the 1st & 2nd floors. There were no bodies of water present.There is sufficient lighting around the facility. Residents' rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers were equipped with grab bars. Inside passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins and sharps. COVID-19 posters were observed posted on the first floor common hallway. Fire extinguishers were last serviced on 11/24/22. First Aid kits was complete. Smoke detectors were observed operational. Hot water temperatures were observed between 115 deg F and 118 deg F in two residents' bathrooms (Rm 111 & Rm 220). Comfortable temperature was observed at 71 deg F per thermostat reading. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (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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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	FACILITY NUMBER: 079201249
	VISIT DATE: 03/07/2023

NARRATIVE

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Prior to licensure, the following shall be corrected and submitted to CCLD by 03/10/23:

Covered trash bins shall be available in each residents' bedroom
Paper towel dispensers in each residents' bathroom
Carbon Monoxide detectors (5) to be installed on 1st & 2nd floors
Controlled substance small refrigerator lock in the medication room to be replaced
Medication room cabinet doors to be repaired for proper closure
Elevator Instructions to be posted inside for emergency use & reference
Old cabinet to be removed and replaced in the dining area

Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with ED and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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