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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600102
Report Date:
12/02/2021
Date Signed:
12/02/2021 11:13:45 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 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:
1
DATE:
12/02/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
John Afanasiev
TIME COMPLETED:
11:15 AM
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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 closing and all residents are to be moved out. LPAs met with licensee and explained purpose of today's visit.
LPA Vado toured the facility with the licensee. LPA observed that all rooms are packed up and vacant. As of 0630hrs this morning R1 moved out of the facility and only R2 remains at this time. R2 was observed in the living room watching television. LPA Vado and licensee spoke to R2 and he indicated that he will be moving today as well but is unsure of time. According to caregiver Eduardo confirmed that R2 is set to move out later today. Caregiver says he was present at the time of R1 moving out at 0630hrs and was informed of the move of R2. Licensee indicated that the land has already been purchased and upon move out of the last resident he will not have access to the home. LPAs observed that the caregiver is loading an open bed pick up truck with furniture and plastic bags to be dumped.
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:
12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/02/2021
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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