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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600102
Report Date: 11/12/2021
Date Signed: 11/12/2021 10:19:56 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:
11/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eduardo SalasTIME COMPLETED:
10:30 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management inspection visit to monitor the facility as it is proposing to close by the end of November 2021. LPA met with caregiver Eduardo Salas and explained purpose of today's visit.

LPA toured the facility with the caregiver as the licensee is not present at this time as he is grocery shopping. All 10 residents remain in the facility as none has been placed as of yet. He believes next week that placement may begin. LPA inspected fresh food supplies in the kitchen and the additional food supplies in the basement level. There are two additional refrigerators in the basement containing fresh food supplies and frozen goods. Emergency food supplies are observed as present in a storage room in the basement. Based on observations made, all food supplies are in place. During tour of the facility all utilities appear to be active and in place. Ambient temperature is warm. According to caregiver everything is in place and staffing is available at all times. He says himself, the licensee, and the wife of the licensee assist in care and supervision. He added that the county Long Term Care Ombudsman also visits the facility frequently but did not visit on this day so far.

At 1000hrs the wife of the licensee arrived at the facility.


No citations issued.

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

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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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