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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201249
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:24:22 PM


Document Has Been Signed on 03/07/2023 04:24 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 CAREFACILITY NUMBER:
079201249
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 44DATE:
03/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Eugenie Broussard, Executive Director
Marina Peckham, Resident Care Director		TIME COMPLETED:
04:40 PM
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During the pre-licensing inspection on 03/07/23, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Component lll presentation with applicant.

During the Component lll presentation, LPA provided applicant information on how to operate the facility within Title 22 regulatory compliance as well as how to avoid common problem areas. Applicant confirmed understanding of regulations discussed and agreed to comply with Title 22 regulations.

Exit interview conducted and a copy of this report was provided to applicant.
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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