079200389-12-29-2022-15-AS-KHOS-CMRNX4-20230104095031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 12/29/2022
Date Signed: 12/29/2022 03:57:34 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
12/20/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20221220114525

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: 38	DATE:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Marina Peckham, Resident Care Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not inform authorized representative of incident in a timely manner.
Staff is not ensuring resident's record files are up to date

INVESTIGATION FINDINGS:

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On 12/29/22 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with Resident Care Director (RCD), gathered information and delivered investigation findings. LPA explained the purpose of the visit with RCD.

Allegation: Staff did not inform authorized representative of incident in a timely manner
During visit, RCD confirmed with LPA that resident's (R1) current authorized representative (POA) was not timely notified of an incident that occurred on 112/11/22. RCD stated R1's record files still had the old authorized representative's contact information which staff used to communicate the 12/11/22 incident.The preponderance of evidence has been met. Thus, this allegation is substantiated.
Continued on next page, LIC 9099-C

Substantiated

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: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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 3

Control Number 15-AS-20221220114525

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: 12/29/2022

NARRATIVE

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Allegation: Staff is not ensuring resident's record files are up to date
During visit, RCD confirmed with LPA that facility staff failed to update R1's authorized representative (POA) information resulting in staff communicating the 12/11/22 incident to the former authorized representative. RCD stated R1's POA did not learn of the incident until 12/12/22. The preponderance of evidence has been met. Thus, this allegation is
substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20221220114525

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: 12/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/20/2023 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs...	1 2 3 4 5 6 7	By POC due date, RCD agreed to complete and submit to CCLD in-service staff retraining on mandatory reporting requirements.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff failing to timely notify authorized representative of an incident which posed a potential health & safety risk to resident in care.	8 9 10 11 12 13 14
Type B 01/20/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.	1 2 3 4 5 6 7	By POC due date, RCD agreed to complete and submit a self certification to CCLD that all residents' record files have been updated to reflect current contact information and that staff will
	8 9 10 11 12 13 14	This requirement was not met as evidenced by old authorized representative records on resident's file which caused a delay in communicating an incident and posed a potential health & safety risk to resident in care	8 9 10 11 12 13 14	ensure current record is maintained for each resident readily available to facility staff and licensing.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

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