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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600102
Report Date: 10/08/2021
Date Signed: 10/12/2021 04:25:28 PM

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:Required - 1 YearANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:John Afanasiev TIME COMPLETED:
01:00 PM
NARRATIVE
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On October 8, 2021, Licensing Program Analyst (LPA) Komal Charitra and Jaime Vado conducted an unannounced annual infection. Upon arrival, LPAs observed signage on the front door. LPAs were greeted by the Administrator, John Afanasiev and explained the purpose of the visit. LPA's were not screened at the entry point and the administrator was not able to provide screening log documentation for residents and visitors.

LPAs toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not present: entry procedures, face coverings, daily monitoring for residents and staff, and 30-day PPE supply. Bathrooms are equipped liquid soap but LPA Vado observed hand towels rather than paper towels. There was a lack of COVID-19 signage throughout the facility. Signs were only posted in the hallway but none observed in the living room area, bathrooms, or kitchen. All rooms are single occupied at this time.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was present. LPAs observed 5 residents and 2 staff present during today's inspection without face coverings.

The facility was not able to provide any documentation for the daily COVID-19 screening for the residents and staff members. According to administrator, all staff and residents are fully vaccinated.

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

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by: failed to proide documentation for daily resident and staff screening logs; failed to provide documentation for visitor screening log; residents and staff not wearing masks; entrance screening procedures; failure to wear face coverings, failure to monitor daily symptom screening for staff and residents; failure to maintain a 30-day supply of PPE; failure to post hand-washing signs in the resident's bathrooms.
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log. The facility staff and residents failed to wear face covering to maintain COVID-19 protocols. The facility failed to have an adequate amount of PPE supply for 30-days.
POC Due Date: 10/15/2021
Plan of Correction
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The administrator/licensee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening for residents and staff members, masking guidance, COVID-19 protocol signage, and maintaining an adequate amount of PPE supply.
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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
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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