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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501662
Report Date: 09/24/2020
Date Signed: 09/24/2020 05:57:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR:MATTHEW NEELEYFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: 55DATE:
09/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Assisted Living Supervisor Desiree EudaveTIME COMPLETED:
05:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ren'ee Arterberry initiated a Case Management Visit pertaining to an incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with the Assisted Living Supervisor Desiree Eudave and the purpose for the visit was discussed. A former resident who shall be referred to as R1 was transported to the hospital for medical care. The hospitalization were not reported to Community Care Licensing/CCL as required per California Code of Regulations Title 22.

Because the hospitalizations and death were not reported to Community Care Licensing as required,


One deficiency cited under California Code of Regulations Title 22

An Exit Interview was conducted via telephone with S2 and hardcopies were provided via email for signatures. Signatures on hardcopies.


Appeal Rights and POC Coversheet supplied
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2020
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRETHREN HILLCREST HOMES
FACILITY NUMBER: 191501662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2020
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Depart may require, including, to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events; date and nature of: death of
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 any resident from any cause regardless of where the death occurred, including hospital, en route to or from a hospital, or visiting away from the facility .Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidence by, the admission of the administrator that the hosptalations and death of R1 were not reported to CCL.
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then train (conduct an In-Service Training) with all medication/technicians informing them of the Reporting Procedures. The administrator shall provide to LPA Arterberry's attention the In-Service Training Agenda and Sign In Sheet by the POC Date of 10/24/2020.

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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2020
LIC809 (FAS) - (06/04)
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