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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600102
Report Date:
11/17/2021
Date Signed:
11/17/2021 02:41:04 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 MANOR
FACILITY NUMBER:
415600102
ADMINISTRATOR:
AFANASIEV, JOHN
FACILITY TYPE:
740
ADDRESS:
909 HILLCREST DRIVE
TELEPHONE:
(650) 474-0645
CITY:
REDWOOD CITY
STATE:
CA
ZIP CODE:
94062
CAPACITY:
12
CENSUS:
9
DATE:
11/17/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
John Afenasiev
TIME COMPLETED:
02:45 PM
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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 licensee and explained purpose of today's visit.
LPA toured the facility with the licensee. LPA observed the living area of the facility and there is one resident present. LPA observed the kitchen and the refrigerator. Food supplies are in place. LPA also observed caregiver Eduardo bringing breads and other food supplies from the basement area which contains food supplies. Facility ambient temperature is warm and utilities are in place based on observations made. LPA interviewed the licensee regarding resident moves and he confirmed one female resident has already moved out as of Monday 11/15/2021. He says that Behavioral Health and Recovery Services (BHRS) case manager Zach was on site today to pick up and bring some residents to receive COVID19 tests as a preplacement requirement in order for those residents to move to new facilities. Licensee also confirmed that BHRS meets with him sometimes via phone call to inform on placement updates and that additional resident will be moving this week. Long Term Care Ombudsman (LTCO) was on site earlier on this day as well. Facility is operating normally and care and supervision is in place.
No citations issued.
Report is reviewed with licensee.
SUPERVISOR'S NAME:
Brenda Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/17/2021
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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