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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201249
Report Date: 03/14/2023
Date Signed: 03/14/2023 02:28:39 PM


Document Has Been Signed on 03/14/2023 02:28 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:
03/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
02:40 PM
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On 03/14/23 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent pre-licensing visit and met with applicant executive director (ED). LPA explained the purpose of the visit with ED. LPA observed COVID-19 routine symptom checks done at front entry with staff wearing face masks. The facility has an approved fire safety clearance for total capacity of ninety (90) residents dated 01/12/23.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens for the residents. Bathrooms were equipped with grab bars and hygiene items. Communal dining room is equipped with sufficient tables and chairs for the residents. All toxins and sharp objects were locked inside the laundry and kitchen areas. Passageways and hallways were free of obstruction. Fire extinguishers were last serviced on 11/24/22. Smoke detectors and Carbon Monoxide detectors were operational. Medication cabinet was locked and first aid kit was complete. All exit doors in the facility are equipped with auditory signals. Hot water temperature is measured at 115 degrees F. LPA observed COVID-19 posters posted in common hallways and bathrooms. Emergency Disaster plans are complete and easily accessible to staff. Comfortable temperature was observed at 71 deg F.

Component III was conducted with ED on prior pre-licensing visit dated 03/07/23.

No issues noted during this pre-licensing inspection. Prior deficiencies noted on 03/07/23 were corrected on 03/14/23. LPA observed the facility is ready to be licensed. This report will be submitted to the central application 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 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)
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