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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501662
Report Date: 07/13/2024
Date Signed: 07/13/2024 03:00:33 PM

Document Has Been Signed on 07/13/2024 03:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR/
DIRECTOR:		KEITH KASINFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 574CENSUS: 71DATE:
07/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Director of Social Work- Lynn PalinTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 7/13/2024. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Operational Requirements: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6) residents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the nine (9) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for nine (9) out of the nine (9) personnel records reviewed.

Staffing: Administrator Certificate for Keith Kasin (70005649740) expires 08/10/2024 and is in the process of being renewed.



Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services.

See 809-C for continuation.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BRETHREN HILLCREST HOMES
FACILITY NUMBER: 191501662
VISIT DATE: 07/13/2024
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Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for nine (9) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

No deficiencies were observed during this inspection. Exit interview was conducted. A copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC809 (FAS) - (06/04)
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