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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601460
Report Date: 12/15/2023
Date Signed: 12/15/2023 12:05:52 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20231207110543
FACILITY NAME:HILLCREST MANOR BOARD & CAREFACILITY NUMBER:
075601460
ADMINISTRATOR:MARTIN BLAIR/DAVID AYALAFACILITY TYPE:
740
ADDRESS:5135 DOMENGINE WAYTELEPHONE:
(925) 755-4777
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
12/15/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Greg Ashby, Licensee
Martin Blair, Administrator		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Uncleared adult resided in facility
Facility stored firearms on facility premises
INVESTIGATION FINDINGS:
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On 12/15/23 at 10AM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct an initial 10- day investigation regarding the above allegations, met with licensee (LC) and delivered investigation findings to LC & administrator. LC stated only the first floor is licensed and his family lives on the second floor which is unlicensed.

At 10:30AM, LPA interviewed LC and obtained the following documents: Personnel record, Resident roster. LPA observed 3 staff (LC, ADM, S1) assisting 4 residents, 2 residents were resting inside their bedrooms while the other 2 were watching TV in the living room. The other resident was out in the community during visit.
Continued on next page, LIC 9099-C



Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20231207110543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HILLCREST MANOR BOARD & CARE
FACILITY NUMBER: 075601460
VISIT DATE: 12/15/2023
NARRATIVE
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Allegation: Uncleared adult resided in facility
Investigation finding: Unfounded
During investigation, LPA observed no uncleared adult residing at the facility. LPA reviewed facility's personnel record and ran a Guardian roster check on all staff working at the facility. LPA observed all staff (LC, ADM, S1) were fingerprint cleared and associated with the facility. LPA observed licensee and family members occupy the second floor of the facility which is unlicensed. Only the first floor of the facility is licensed. LPA observed all residents (R1, R2, R3, R4, R5) live on the first floor of the licensed facility.

Allegation: Facility stored firearms on facility premises
Investigation finding: Unfounded
At 11AM, LPA toured the facility with LC including but not limited to residents' bedrooms, bathrooms, laundry room, kitchen and garage. LPA checked residents' bedroom closets, cabinets, drawers, laundry cabinets, kitchen drawers and cabinets and garage. LPA did not find any firearms or ammunition in any of these areas. LC and ADM stated they do not keep or store any firearms or ammunitions at the facility.

This department had investigated the complaint alleging that an uncleared adult resided at the facility and that facility stored firearms on facility premises. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2