306005871-3-19-2025-22-AS-ARJR-DEWV55-20250319160718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005871
Report Date: 03/19/2025
Date Signed: 03/19/2025 04:07:32 PM

Document Has Been Signed on 03/19/2025 04:07 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 SENIOR LIVING		FACILITY NUMBER:	306005871
ADMINISTRATOR/ DIRECTOR:	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: 2	DATE:	03/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:41 PM
MET WITH:	Blanca Gonzalez-Caregiver, Eduardo Capistrano-House Manager, Eisenhower Belo-Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:19 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Blanca Gonzalez. Administrator (AD) Mary Jean Alvarado was notified via telephone by staff.

For today’s visit, LPA observed a total of two residents in care and two staff member on duty.

LPA observed the AD certificate for AD Mary Jean Alvarado which expires on June, 08, 2026.

LPA Ramirez toured the interior and exterior portions of the facility with Caregiver Eisenhower Belo. The facility is a single level structure and is licensed for five non-ambulatory, one bedridden and has a Hospice waiver for four. For this visit, there are a total of five residents in care. There are a total of six bedrooms, of which five are private resident bedrooms. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector were tested and operational. There are a total of four restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 105.4-105.6 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located by the dining room. Fire extinguisher was service on May 09, 2024.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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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Document Has Been Signed on 03/19/2025 04:07 PM - It Cannot Be Edited

Created By: Alvaro Ramirez Jr. On 03/19/2025 at 02:56 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 SENIOR LIVING	FACILITY NUMBER: 306005871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that two of two resident files did not have a pre-admission appraisal.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	Licensee to email two of two updated pre-admission appraisals for two of two residents in care.

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

LICENSING EVALUATOR NAME:

Alvaro Ramirez Jr.

LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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 SENIOR LIVING	FACILITY NUMBER: 306005871
	VISIT DATE: 03/19/2025

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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the dining room. Facility had back-up emergency food and water supply. LPA observed that the First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. Medications are locked in a cabinet in the garage.

For the exterior portion, LPA Ramirez observed a shaded area with patio furniture, and the grounds were free of any hazards. There is one gate in the backyard. No bodies of water were observed.

LPA reviewed two resident files and three staff files. LPA interviewed residents and staff present.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative.

A copy of this report and Appeal Rights were provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC809 (FAS) - (06/04)

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