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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501662
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:30:28 PM


Document Has Been Signed on 09/07/2022 02:30 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR:SUZANNE FAIRLEYFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: 309DATE:
09/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Matthew Neeley - Chief Executive Officer TIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst(s) LPA Flores conducted a case management visit to follow up on incident report submitted to the department on 8/31/22 reporting an altercation between Resident #1 and staff #1. LPA Flores met with Matthew Neeley Chief Executive Officer and explained the reason for the visit.

On 8/31/22 facility reported to the department via faxed incident report and SOC 341 that on the evening of 8/30/22 resident #1 (R1) had pushed walker, slapped, and threw water at staff #1 (S1). On 8/31/22 Director of Residential Care checked on R1 in the morning and R1 reported that S1 had grabbed R1's arm and left bruises on left arm. On 9/7/22 LPA Flores conducted a case management visit, interviewed Chief Executive Officer, Director of Resident Care and R1. LPA Flores collected copies of R1's physician's report date: 5/20/22 and 5/17/22, admissions agreement, face sheet, appraisal needs and care plan, City of La Verne Police Department business card with report #220900030, and personnel record for S1. S1 is currently off schedule until internal investigation is concluded.

No deficiencies were given during this visit. Further investigation is needed at this time. LPA will return at a later time.

Exit interview was conducted with Chermaine Williams - Director of Resident Care and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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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