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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 12/13/2021
Date Signed: 12/13/2021 04:24:16 PM



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
01/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210114155706
FACILITY NAME:HILLCREST MEMORY CARE LIVINGFACILITY NUMBER:
079200389
ADMINISTRATOR:CECILY PALMAFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 49DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cecily Palma, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident eloped from facility
Staff sleeping during shift
INVESTIGATION FINDINGS:
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On 12/13/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit to deliver the findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Resident eloped from facility
Investigation Finding: SUBSTANTIATED
Upon investigation, it was found that R1 had eloped from the facility on 9/20/20. Facility cameras captured R1 exiting the physical plant on 3:22 am but was not discovered missing until approximately 5:00 am. The local Police Department was contacted, who found and returned R1 to the facility. R1’s Physician’s Report confirms that R1 could not leave unassisted.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 5
Control Number 15-AS-20210114155706
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 MEMORY CARE LIVING
FACILITY NUMBER: 079200389
VISIT DATE: 12/13/2021
NARRATIVE
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Allegation: Staff sleeping during shift
Investigation Finding: SUBSTANTIATED
During investigation, it was found that an internal review determined that an on-duty staff person had fallen asleep the evening of 9/20/20 and did not hear the door alarm when R1 exited the facility at 3:22 am (as observed in the facility video recordings). It was also found that three other on-duty staff persons had also not heard the alarm until approximately 5:00 am.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210114155706
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 MEMORY CARE LIVING
FACILITY NUMBER: 079200389
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
CCR
87705(b)(2)
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(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials
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Administrator corrected deficiency on 09/21/20. Increased monitoring of residents and checking of all door alarms were implemented by staff on 09/21/20.
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This requirement was not met as evidenced by R1 captured on video leaving the facility without staff knowing on 09/20/20 at 3:22AM which posed a potential health & safety risk to resident in care.
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Type B
12/13/2021
Section Cited
CCR
87411(f)
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(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This requirement was not met as evidenced by:
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Administrator corrected deficiency on 9/21/20. Administrator conducted an internal investigation and terminated staff (S1) on 09/21/20. Administrator also increased the sound of door alarms to the highest
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Staff (S1) sleeping on the job which posed a potential health & safety risk to residents in care
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level to ensure all staff hear any door alarms at all times at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210114155706

FACILITY NAME:HILLCREST MEMORY CARE LIVINGFACILITY NUMBER:
079200389
ADMINISTRATOR:CECILY PALMAFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 49DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cecily Palma, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident suffered serious injuries while in care resulting in hospitalization
INVESTIGATION FINDINGS:
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On 12/13/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit to deliver the findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Resident suffered serious injuries while in care resulting in hospitalization
Investigation Finding: UNSUBSTANTIATED
During investigation, it was found that R1 was assessed as being ambulatory without need of an assistive device, was not a fall risk, and was independent in moving about, transferring, and toileting. Records indicate that R1 was to be checked on 2x per shift overnight. R1 had a private caregiver on duty from 3:00 pm to 9:00 am every night, and this person was present the evening of 11/15/20.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20210114155706
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 MEMORY CARE LIVING
FACILITY NUMBER: 079200389
VISIT DATE: 12/13/2021
NARRATIVE
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 At 5:30 pm the private caregiver observed a bruise to R1’s upper left arm, then at 11:00 pm notified staff that R1 was exhibiting a change in condition. 911 was immediately called,

R1 was transferred to hospital, where R1 was determined to have had an unwitnessed mechanical fall. R1 was not re-evaluated for a change to the care plan, as R1 did not return to facility. There is insufficient evidence to determine that R1 suffered injuries specifically due to neglect or lack of care & supervision.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5