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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002060
Report Date: 04/10/2025
Date Signed: 04/10/2025 12:47:50 PM

Document Has Been Signed on 04/10/2025 12:47 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLCREST RESIDENTIAL CARE #2FACILITY NUMBER:
306002060
ADMINISTRATOR/
DIRECTOR:		EDUARDO CAPISTRANOFACILITY TYPE:
740
ADDRESS:6462 E. CALLE DEL NORTETELEPHONE:
(714) 281-4030
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 5DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Mary Jean AlvaradoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff, and explained the reason for the visit. The licensee was present upon arrival and the Administrator arrived about an hour later.

During the inspection, LPA Haley observed a locked closet right next to the front door used to store resident medications and resident files. Under the staircase, there is a locked storage space for additional hygiene items for the residents.

Resident bedrooms were clean, organized, and had the necessary elements and were in compliance with regulation guidelines. Resident bathrooms were clean and organized as well. Hot water temperatures were measured at 105 degrees Fahrenheit. Hazardous items are kept under the sink in a locked cabinet.

The kitchen is kept locked at all times when staff is not present. A perishable and non-perishable food supply that meets regulation requirements was observed. Knives are kept hidden in the pantry. All four burners and the warmer on the stove were operational. No hazardous cleaning chemicals were observed under the sink. Between the kitchen and garage is a locked office area where staff files are kept.

The garage remains locked and inaccessible to residents at all times. The garage was clean and organized. Two cars were parked in the garage. A refrigerator with plenty of perishable food items was observed as well as an emergency supply of water being stored in the garage. A laundry area equipped with a washer and dryer was observed.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/10/2025 12:47 PM - It Cannot Be Edited


Created By: Jerome Haley On 04/10/2025 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST RESIDENTIAL CARE #2
FACILITY NUMBER: 306002060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 2 of 5 resident medications were being stored in a daily medication organizer which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Administrator Alvarado will conduct an in-service training on medication administration procedures. Administrator Alvarado will email LPA Haley the in-service sign in sheet and a summary of the topics covered during the training.
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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLCREST RESIDENTIAL CARE #2
FACILITY NUMBER: 306002060
VISIT DATE: 04/10/2025
NARRATIVE
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The backyard was organized, and walkways were free of obstruction. A storage shed with facility supplies and hazardous cleaning chemicals was observed. A jacuzzi with a secured covering under a shaded patio area was observed. There’s a locked storage room with plenty of non-perishable food items for the residents. An emergency food supply was observed. There were plenty of accessories for facility use being stored in the locked storage room. Tables and chairs were observed in the backyard area.

Smoke detectors, and the carbon monoxide detector tested operational. A fully charged fire extinguisher was observed mounted on the wall in the kitchen.

Emergency evacuation drills were conducted monthly. The last evacuation drill was conducted March 5, 2025.

During the inspection, 4 resident files were reviewed, 5 resident medications reviewed, and 3 staff files were reviewed during the visit.

A deficiencies will be cited as a result of today’s visit.

An exit interview conducted, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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