079200389-6-30-2022-15-AS-BFOG-CH4RNQ-20220808131044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 06/30/2022
Date Signed: 06/30/2022 02:33:48 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
02/28/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220228144610

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: 44	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	Marina Peckham, Resident Care Coordinator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Resident had to be hospitalized while in care
Resident sustained a fracture while in care
Staff did not ensure a resident was properly fed while in care
Resident sustained multiple falls while in care
Resident is not being changed regularly while in care
Staff did not properly report incidents involving a resident

INVESTIGATION FINDINGS:

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On 06/30/22 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Neglect/Lack of care: Facility staff neglected resident resulting in hospitalization for an infection in her face
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was sent to the hospital on 02/04/22 via ambulance for chief complaint of right facial swelling. On 02/11/22, R1 was discharged from the hospital with a visit diagnosis of parotitis and MRSA.

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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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-20220228144610

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: 06/30/2022

NARRATIVE

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The hospital discharge report indicated parotitis is the swelling of the parotid glands. Common causes of this condition include viruses, bacterial infections, diabetes, tumors or stones in the saliva glands. Staff were interviewed and generally reported that changes in R1’s baseline condition were not observed prior to 02/04/22. Staff reported R1 did not complain of pain. Staff did not know what caused the infection. R1 declined to be interviewed. Other residents interviewed reported no serious concerns. 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.

Allegation: Neglect/Lack of Care: Facility staff failed to provide appropriate care resulting in R1 sustaining a rib fracture
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was admitted at the hospital with an 11^th rib fracture on 02/04/22. Hospital doctor explained that this type of fracture is a single fracture which typically don’t require treatment, only pain management. Staff interviewed reported they were not aware that R1 had a rib fracture. Staff generally denied that R1 had any accidents/trauma/falls that contributed to the injury. One staff reported that she found R1 on the floor of her bedroom attempting to get up on an unknown date. Staff stated R1 did not express any pain. R1 did not know how she got on the floor. Staff did not know what could have caused R1’s rib fracture. Staff stated R1 required assistance with using the toilet, getting dressed, showering and brushing her teeth. Staff stated R1 was able to go up and down the stairs unassisted. R1 declined to be interviewed. Other residents interviewed had no serious concerns to report. 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.

Continued on next page, LIC 9099-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220228144610

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: 06/30/2022

NARRATIVE

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Allegation: Staff did not ensure resident was properly fed while in care
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, S3 stated that R1 was one of her assigned residents. She would assist R1 with changing her diapers, bathing, eating and cleaning her room. She stated R1 was independent and would walk downstairs for breakfast, lunch and dinner. R1 would eat meals 3 times a day along with some snacks whenever she requests them. Facility assessment conducted 07/14/21 by staff (S2) show R1 requires no assistance in eating and is not diabetic. S3 stated that due to R1’s dementia, she eats with her hands in a confused/disoriented way. 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.

Allegation: Resident sustained multiple falls while in care

Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was able to walk without assistive devices. R1 was able to transfer in and out of bed independently without assistance. R1 did not have a history of falls. She was stable when walking and did not stumble. Staff reported R1 did not sustain any significant injuries while residing at the facility other than a urinary tract infection (UTI). R1 did not have any incident reports involving falls or serious injuries. Administrator stated that since R1 was capable to get up on her own, it was possible that R1 may have sustained unwitnessed falls while in care. 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.

Continued on next page, LIC 9099-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220228144610

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: 06/30/2022

NARRATIVE

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Allegation: Resident is not being changed regularly while in care
Investigation Finding: UNSUBSTANTIATED
Review of resident’s (R1) service plan show R1 had an assigned care aide staff (S3) who provided R1 assistance with bathing (2X per week), daily toileting (AM, PM), dressing (AM, Bedtime), changing her diapers (AM, PM) and cleaning her room. 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.

Allegation: Staff did not properly report incidents involving a resident
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, an incident report dated 02/04/22 show staff (S2) called 911, sent resident (R1) to the hospital for evaluation & treatment of a huge lump on the side of her face and neck. R1’s authorized representative was notified of the incident. 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.

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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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