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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600102
Report Date: 11/23/2021
Date Signed: 11/23/2021 12:18:52 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: 5DATE:
11/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:John AfansievTIME COMPLETED:
12:30 PM
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On this day Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra 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.

LPAs 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. Basement food supplies were observed as in place. Emergency food supplies are observed as in place in basement storage area. LPAs interviewed licensee and according to him a resident moved out earlier this morning and another left to get TB tested for a proposed move to another facility. In total 5 residents have moved out and 5 remain at this time. Utilities are in place according to licensee and caregiver Eduardo when interviewed. Caregiver and licensee are present on this day providing care and supervision to the remaining residents.

LPA Vado also informed licensee that if the target move out date for all residents surpass 11/30/2021, that the facility must remain in operation providing care and supervision to the residents until all are moved out. He acknowledges LPA and agrees that the residents will still receive care and supervision if all residents are not all moved out to other facilities by the end of November 2021.

No citations issued.

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

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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