306005871-11-2-2022-22-AS-ETAA-CKST5U-20221102142607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005871
Report Date: 11/02/2022
Date Signed: 11/02/2022 02:26:18 PM

Document Has Been Signed on 11/02/2022 02:26 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HILLCREST SENIOR LIVING		FACILITY NUMBER:	306005871
ADMINISTRATOR:	ALVARADO, MARY JEAN		FACILITY TYPE:	740
ADDRESS:	6468 CALLE DEL NORTE		TELEPHONE:	(714) 749-7237
CITY:	ANAHEIM HILLS	STATE: CA	ZIP CODE:	92807
CAPACITY:	6	CENSUS: 5	DATE:	11/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:54 PM
MET WITH:	Mary Jane Alvarado		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator Mary Jean Alvarado arrived after the inspection. The facility is a single-level structure and licensed for six ambulatory of which five may be non-ambulatory with a hospice wavier for four. One may be bedridden. This facility offers Resident Care Facility for the Elderly/Dementia. At about 12:54 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. There were 5 resident rooms, 1 room was a shared room.Facility offers a staff room inaccessible to resident. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and hot water was measured at 115.1 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Kitchen was in good repair with cleaning supplies and sharps inaccessible to residents in care. LPA noticed unlocked staff medications in the pantry. Staff immediately removed medications. Facility offers a 2-car garage mainly used for storage with an operational washer and dryer and emergency supplies.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
	VISIT DATE: 11/02/2022

NARRATIVE

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For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Backyard also contained a refrigerator and freezer.

LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster Plan of the facility.

LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for resident or resident use.

For this visit, one deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Administrator Mary Jean Alvarado and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/02/2022 02:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one. Staff medications were kept in an unlocked pantry, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2022
	Plan of Correction
1 2 3 4	Staff immediately removed medication and stored it away in a locked location.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

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