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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201249
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:03:47 PM


Document Has Been Signed on 02/23/2024 02:03 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: 41DATE:
02/23/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Eugenie Broussard, AdministratorTIME COMPLETED:
05:30 PM
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On 02/23/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check as a result of the department receiving a priority 2 complaint.

During the health and safety check, LPA observed a total of 5 staff members and 41 residents at the facility. LPA toured facility with administrator, 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 the health and safety check. 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: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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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