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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600102
Report Date: 10/08/2021
Date Signed: 10/11/2021 09:17:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HILLCREST MANORFACILITY NUMBER:
415600102
ADMINISTRATOR:AFANASIEV, JOHNFACILITY TYPE:
740
ADDRESS:909 HILLCREST DRIVETELEPHONE:
(650) 474-0645
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:12CENSUS: 10DATE:
10/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:John AfenasievTIME COMPLETED:
12:00 PM
NARRATIVE
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On this day at 0900hrs Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannouced case management inspection visit to discuss closure of the facility. LPAs met with licensee John Afanasiev and explained purpose of today's visit.

LPAs toured the facility with the licensee. LPAs discussed closing procedures on this day. According to licensee there has been an offer accepted the week of September 27th. This was not communicated with the Department. Licensee indicated he has notified behavioral health and placement of the residents are being handled by them. During today's visit Long Term Care Ombudsman (LTCO) Tom Barrett arrived and spoke to LPAs and confirmed details regarding facility closure and placement of closure


Deficiencies of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 are observed and cited on atached LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report reviewed with licensee.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HILLCREST MANOR
FACILITY NUMBER: 415600102
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited

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Eviction Procedures - The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.
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This requirement has not been met as evidenced by: Licensee informed LPA Vado and Charitra during inspection visit that that an offer has been accepted and notification to the Department has not been sent.
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Type B
10/13/2021
Section Cited

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Eviction Procedures. A written report of any eviction shall be sent to the licensing agency within five (5) days.
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This requirement has not been met as evidenced by: Licensee did not notify the Department of intent to close the facility within 5 days. The Department learned of the intent to close when interviewing licensee in person. This was also confirmed via LTCO Barrett that was present during visit.
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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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
LIC809 (FAS) - (06/04)
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