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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501662
Report Date: 07/20/2021
Date Signed: 07/21/2021 08:39:10 AM

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: 62DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Sur FairleyTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Linda Almaraz and Alberto Lopez conducted an annual required visit. LPA's met with CEO Matthew Neeley, Administrator, Sue Failey and Director of Facility of Operations, Dan Townsend and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is approved.

The facility is located in a large campus that includes independent living, assisted living, memory care and skilled nursing. The assisted living and memory care buildings were toured. Maple court and Birch Court have 2 floors. Both floors were toured. The first floor consist of resident bedrooms, kitchenette, dining room and activity room. Bedrooms had required furniture. The food in the kitchen was sufficient supply of 2 days perishable and 7 days non-perishable. The common areas such as living room and dining area are clean and have the required furniture. The patios have a shaded area and sitting area. Medications are centrally stored and locked. Carbon monoxide detectors were checked and Fire Extinguishers were present all around the facility. Smoke alarms in the Birch Court side was not operable.

Bathrooms, toilets, hand washing and shower/bathtub were toured. During the tour the following bathrooms water temperature were not within the required range; Room 174, 183, 178, 138 and 144. Medication administration record (MAR) logs for resident #1 was signed off although the medication was not given yet, and resident #4's MAR log was not signed off as given for July 16th although it was given to the resident. A medication was missing for Resident #2.

Deficiencies cited under California Code of Regulations Title 22
An exit Interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 07/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPA's and facility Manager observed water temperature on several bathrooms in the Birch and Maple Court side not within the required range. Birch Court side: Room 174 was at 127.5 degrees F, Room 183 was at 123.4 F, and Room 178 was at 124.7 F. Maple Court side: Room 138 was at 121.1 F, and Room 144 was at 122.4 degrees F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2021
Plan of Correction
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(1) Administrator shall adjust the water temperature within the required range of 105-120 degrees F within 24 hours.
(2) Administrator will monitor the water reading in all bathrooms daily and will document the reading for 7 days. Administrator will send a copy of the log to LPA by 7/27/21.
Type A
Section Cited
CCR
87465(c)(2)


This requirement is not met as evidenced by: While reviewing medication, LPA's and staff observed Resident #1's Medication Administration Record (MAR) log was signed off as given and the medication was not administered. Resident #2's prescription of Milk of Magnesia was missing. Resident #4's MAR log was missing signatures for July 16th although the medication was administered. AResident #4's afternoon medication was also not administered on time for today on 7/20/21.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 residents medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2021
Plan of Correction
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Administrator shall conduct medication administration training for all staff who administer medication. Administrator will send LPA proof of material covered and in-service sign in sheet by POC due date.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 07/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: LPA's, Administrator and Director of Operations tested the smoke alarms in Birch Court and were not operable. Upon testing the alarm did not go off.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having an operable smoke alarm in the birch court side of the building which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2021
Plan of Correction
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(1) Administrator will have maintenance repair the alarm imediately.
(2) Administrator shall develop a plan to check the smoke alarms on all buildings frequently and will submit plan to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3