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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:00:05 PM

Substantiated


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
07/02/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200702083746
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: 40DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eleina Ridolfi, Executive Director
Marina Peckham, Resident Care Coordinator		TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff did not notify resident's authorized representative of a change in condition
Staff did not prevent the spread of scabies
INVESTIGATION FINDINGS:
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On 03/16/22 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced visit to deliver the complaint investigation findings on the above allegations. LPA met with resident care coordinator (RCC) & executive director (ED) and explained the purpose of the visit.

Allegation: Staff did not notify resident's authorized representative of a change in condition
Finding: SUBSTANTIATED
On 11/25/19, R1 had a fall and sustained a head injury at the facility. POA reported she was not told that R1 was sent to the hospital, sustained a head injury requiring staples. POA only learned of the severity of the injury after R1 was discharge from the hospital and was released back to the facility.

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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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 6
Control Number 15-AS-20200702083746
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: 03/16/2022
NARRATIVE
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Allegation: Neglect/Lack of Supervision – staff failed to prevent the spread of scabies.
Finding: SUBSTANTIATED
Based on interviews and record reviews, facility had multiple scabies outbreaks in the past year, including after the COVID lockdown. Facility failed to adequately prevent the spread of scabies resulting in several residents and staff contracting it at various times in the past year. Per staff statements, administration failed to take prompt and necessary action when suspicions of scabies were brought to their attention. When residents were diagnosed with scabies, only the infected residents were treated and his/her beddings/clothing washed. No additional cleaning was done in common areas following scabies outbreaks. Other residents were not treated to prevent the spread until recent outbreaks in June 2020 and October 2020.
The preponderance of evidence standard has been met, therefore the above allegation(s) were found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction (POC) by plan of correction due date 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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20200702083746
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: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2022
Section Cited
CCR
87466
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Observation of Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any
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By POC due date, executive director agreed to submit to CCLD staff in-service retraining on proper care and supervision, frequent resident checks and notifications of any changes in condition with
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This requirement was not met as evidenced by staff not notifying resident's authorized representative of change in condition which posed an immediate risk to residents in care.
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authorized representatives and, resident's physician within 24 hours of occurence.
Type A
03/31/2022
Section Cited
CCR
87470(b)(a)(1)
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Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2), assigned staff and volunteers, regardless of having direct contact with clients, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the communicable disease.
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By POC due date, executive director will submit to CCLD a written infection control mitigation plan to be implemented by staff whenever there is an outbreak of communicable disease at the facility.
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This requirement was not met as evidenced by the spread of scabies among residents and staff which posed an immediate health & safety risk to residents in care
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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: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
07/02/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200702083746

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: 40DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eleina Ridolfi, Executive Director
Marina Peckham, Resident Care Coordinator		TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Resident's sustained multiple falls resulting in fractured ribs
Resident was punched in the face by another resident
Staff did not ensure that resident was adequately fed
Staff did not meet resident's hygiene needs
INVESTIGATION FINDINGS:
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On 03/16/22 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced visit to deliver the complaint investigation findings on the above allegations. LPA met with resident care coordinator (RCC) & executive director (ED) and explained the purpose of the visit.

Allegation: Resident's sustained multiple falls resulting in fractured ribs
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) is ambulatory without assistive device and frequently walks all over the facility. R1 has a documented history of fainting and falls at the facility since 11/10/19. On 02/19/20, R1 had an unwitnessed fall and was sent to the ER when he was found. X-rays were not done at the hospital at that time. He returned to ER 3 additional times because he expressed pain and discomfort. X-rays were finally done on 02/26/20 and he was diagnosed with multiple acute left sided rib fractures and multiple healing right rib fractures.

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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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 6
Control Number 15-AS-20200702083746
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: 03/16/2022
NARRATIVE
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Allegation: Resident was punched in the face by another resident
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, LPA observed there was no incident report which showed resident (R1) was punched in the face by another resident. An unusual incident report dated 11/26/2019 documented that on 11/25/2019, resident (R1) attempted to hit medication technician (MT), missed and fell to the ground causing injury to his head. R1 was taken to the hospital where he was treated and released back to the facility with no change in medication. Other incident reports on R1 dated 02/20/20 & 2/27/20 showed R1 was sent to the hospital several times due to an un-witnessed fall and complaints of pain & discomfort.

Allegation: Staff did not ensure that resident was adequately fed
Investigation FInding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was admitted at the facility on 08/28/2019 with a diagnosis of Alzheimer’s disease/Dementia and weighed 139.8 pounds. Staff always remind R1 to go to meals as he tends to forget and not participate in meals. He is ambulatory and not on any special diet. Staff serves 3 meals and snacks daily to residents at the facility. Staff stated R1 prefers to eat in his apartment although he is encouraged to eat in the dining room and drink fluids. Staff stated R1 refuses to eat his meals because he wanders aimlessly without obtainable purpose and has a history of removing items from walls in hallways and removing things from another resident’s room when doors are open. He needs encouragement to stay awake throughout the day as R1 tends to sleep all day.

Allegation: Staff did not meet resident's hygiene needs
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff stated they conduct frequent hygiene checks daily to change soiled clothes or undergarments due to R1’s inability to realize or refusal to change undergarments/soiled clothing. At times, resident (R1) becomes combative when staff assists him with changing clothes due to R1’s inability to know the need to change clothing on a daily basis.

Although the allegation(s) 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. 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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
07/02/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200702083746

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: 40DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eleina Ridolfi, Executive Director
Marina Peckham, Resident Care Coordinator		TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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2
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5
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Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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On 03/16/22 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced visit to deliver the complaint investigation findings on the above allegations. LPA met with resident care coordinator (RCC) & executive director (ED) and explained the purpose of the visit.

Allegation: Staff did not seek medical attention for resident in a timely manner
Investigation Finding: UNFOUNDED
Based on interviews and record reviews, facility staff called 911 after finding R1 on the floor following an unwitnessed fall on 02/19/20. On 02/20/20 and 02/26/20, R1 was sent back to the hospital ER when R1 expressed pain and discomfort. On 2/22/20, R1 was sent to the hospital ER at the request of his wife who observed him to be in pain during visit although he did not express any pain in the ER.

This department had investigated the complaint alleging that facility staff did not seek medical attention for R1 in a timely manner. We have found that the complaint was unfounded. Exit Interview conducted and a copy of this report provided via email.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6