079200389-4-7-2022-15-AS-KHOS-CDLKLL-20220418080008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:52:21 PM

Unsubstantiated

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
12/23/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20201223113555

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	CECILY PALMA		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 40	DATE:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Marina Peckham, Resident Care Coordinator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care
Staff did not properly report an incident regarding a resident

INVESTIGATION FINDINGS:

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On 04/07/22 at 3:10PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit and met with resident care coordinator (RCC) to deliver the investigation finding. LPA explained the purpose of the visit with RCC.

Allegation: Resident sustained an injury from a fall while in care
Investigation Finding: Unsubstantiated
R1 was first admitted to the facility on 11/06/20. R1 is ambulatory without an assistive device and loves to walk all over the facility. LPA's review of R1's facility assessment records show R1 as a fall risk. Two incident reports dated 11/17/20 and 12/08/20 were submitted to CCLD. Incident reports describe R1 had discoloration on her forehead, tailbone, bottom, redness on both knees and a sprained ankle. A letter issued by resident care director (RCD) to R1's primary care physician (PCP) dated 12/08/20 describe R1 as putting herself on the floor multiple times per day and that she also tried climbing over fences & other furniture. RCD stated POA was made aware of this and has witnessed these incidents a few times. RCD stated staff are trying their best to closely monitor R1. LPA's review of hospital discharge report dated 12/06/20 show R1 had severe bruising on her buttocks most likely a result of an accidental fall per attending physician. Incident report dated 12/08/21 showed type of incident as a medical emergency with no written cause of injury.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20201223113555

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: 04/07/2022

NARRATIVE

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Allegation: Staff did not properly report an incident regarding a resident
Investigation Finding: Unsubstantiated
LPA's review of facility's SIRs show facility reported 2 incidents on R1 to CCLD dated 11/17/20 and 12/08/20. First SIR described R1 was found on the floor by staff during rounds on 11/15/20. Per SIR, R1 had discoloration on her forehead, tailbone and redness on both knees. R1 was sent out to Kaiser hospital for evaluation around 11:45AM and POA was called and notified. Hospital evaluated R1 with no injuries and no new orders for treatment. R1 returned to the facility on the same day, 11/15/20. Second SIR show R1 was sent to Kaiser hospital on 12/06/20 at 1:30PM for evaluation. Per report, R1 had discoloration on her bottom and her ankle was swollen. POA was also called and notified.

Per hospital discharge report, R1 had a sprained ankle, rib fracture and compression fracture of the spine. LPA's review of the hospital discharge report show cause of injury was an accidental fall. Per report, no new orders were given to R1 and that fractures will heal over time. R1 returned to the facility on 12/06/20 and POA was called/notified. POA decided to remove R1 from the facility on 12/08/20 after the hospital told POA that R1 had severe bruising on her buttocks most likely a result of a fall. POA took R1 home on 12/08/20.

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

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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