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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 08/05/2020
Date Signed: 08/05/2020 12:33:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HILLCREST ROYALEFACILITY NUMBER:
565800734
ADMINISTRATOR:INGA JAKOBOVICHFACILITY TYPE:
740
ADDRESS:190 EAST HILLCREST DRIVETELEPHONE:
(805) 371-0035
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:145CENSUS: 95DATE:
08/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Inga JakobovichTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Desaree Perera initiated Case Management - Incident visit. The purpose of this visit is to follow up on a special incident report (SIR) submitted to the department on 07/31/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays visit was conducted via FaceTime with administrator Inga Jakobovich at 11:08am.

It was reported that on 07/30/2020, at approximately 8:30pm facility received a call by the family of Resident #1 (R1) informing that staff #1 (S1) inappropriately touched R1. Police was contacted immediately and arrived at the scene. Police conducted interviews and gathered evidence. Paramedics also checked R1 and did not find any immediate harm. S1 was suspended pending investigation.

A telephone interview was conducted with administrator on 08/04/2020 at 1:12pm to obtain additional information regarding the incident. During today's virtual visit, LPA conducted a tour of the physical plant at 11:24am and requested pertinent documentation relating to the incident at 11:45am. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time.

Exit interview conducted via telephone and report was emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
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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