079200389-8-26-2022-15-AS-KHOS-CHTLFH-20220831084309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:05:02 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
08/23/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220823105951

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	DONNA BAUTISTA- COLMENARES		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 41	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Donna Bautista Colmenares, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility did not issue a proper refund

INVESTIGATION FINDINGS:

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On 08/26/22 at 3:55PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the finding of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Facility did not issue a proper refund
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, authorized representative (POA) confirmed with LPA on 08/26/22 that he received the final refund check from the executive director (ED) of the facility. ED stated that there was delay in processing the final refund check due to statement and invoice discrepancies which she explained to POA who understood and agreed to the final refund check amount. A final refund check was issued to POA on 08/24/22 by ED. 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.

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: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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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