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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501662
Report Date: 07/21/2023
Date Signed: 07/21/2023 05:10:57 PM


Document Has Been Signed on 07/21/2023 05:10 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:KEITH KASINFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Keith Kasin, administrator and Staff#2TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Staff#2, social worker and Keith Kasin, administrator. LPA explained the reason for the visit. The facility is licensed to serve fourteen (14) ambulatory residents and 560 non-ambulatory. Facility cares for elderly residents and had approved six (6) hospice residents. Annual licensing fees are current.

During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications and records, and reviewed staff/residents’ records.



The facility is a large campus that includes independent living, assisted living, memory care and skilled nursing. LPA and staff#2 toured the assisted living and memory care buildings. Assisted living buildings are Maple Court, Birch Court, and Cedar Court. Maple Court building is connected to Birch Court building which is a two story building. The building had resident bedrooms, kitchenette, dining room, activity room, beauty salon, library, and kitchen. Memory care building is Southwoods Lodge which is a single story building. Residents’ rooms are furnished with appropriate furniture for residents’ comfort. The hallways and stairways are clear and free of any obstructions. The required evacuation chairs are located at the second-floor stairways. Bathrooms are furnished with grab bars and nonskid surfaces. (-continued in 809C-).
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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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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
VISIT DATE: 07/21/2023
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Common areas are observed for the ability to safely serve the needs of the residents. Hot water temperature is in a range of 113.5 to 114.4 degrees Fahrenheit which is within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies are observed. Medications are centrally stored, locked and inaccessible to residents in care. Elevators are operating at the time of the visit. Cedar Court is a separate building across from Maple Court and Birch Court. Resident rooms were observed to have all the required items. Memory care, Southwoods is located across from Cedar Court. The memory care unit requires a code to enter. The building was toured and was observed to contain all required items.

Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens, and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility.

Smoke detectors and carbon monoxide detectors are operational. Fire extinguishers are located throughout each building and the last service is 12/2/22. The grounds are properly maintained and there were no hazards observed. No bodies of water observed.

Residents/ staff records were reviewed and current. Medications are documented properly and given as prescribed.



Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held with administrator. A copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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