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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 01/20/2023
Date Signed: 01/20/2023 05:01:59 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
08/23/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210823135616
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:
01/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eugenie Broussard, Administrator
Crystal Sheehan, Resident Care Coordinator		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Insufficient staffing to meet residents' needs
Untrained staff
INVESTIGATION FINDINGS:
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On 1/20/2023 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator, Eugenie Broussard and Resident Care Coordinator, Crystal Sheehan.

During the course of investigation, LPA interviewed 6 staff, 1 witness, and complainant. LPA obtained and reviewed 3 staff medication training documents. LPA also reviewed 5 resident files.

Insufficient staffing to meet residents' needs
Interview with staff revealed that during the time period of July 2021 to September 2021, facility was short staff and sometime there would be 2 caregivers working. Staff stated that other departments would help caregivers when residents require 2-person assist. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 4
Control Number 15-AS-20210823135616
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: 01/20/2023
NARRATIVE
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Untrained staff
LPA reviewed medication training documents for 3 staff. LPA observed 2 out of 3 staff only had medication training in 2017 and/or 2020. The two staff did not have training documents in 2021.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210823135616
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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services... to meet their needs.
This requirement is not met as evidence by:
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Facility has agreed to create a written plan to address insufficient staffing and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by having insufficient staff which poses a potential health and safety risk to the persons in care.
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Type B
02/10/2023
Section Cited
CCR
87411(c)
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Personnel Requirements - General. All RCFE staff who assist residents...shall receive initial and annual training...
This requirement is not met as evidence by:
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Facility has agreed to create a written plan to update staff's medication/other training and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having updated medication trainings for staff which poses a potential health and safety risk to the persons 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
08/23/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210823135616

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:
01/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eugenie Broussard, Administrator
Crystal Sheehan, Resident Care Coordinator		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff are not following the proper protocol for COVID-19
INVESTIGATION FINDINGS:
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On 1/20/2023 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrator, Eugenie Broussard and Resident Care Coordinator, Crystal Sheehan.

During the course of investigation, LPA interviewed 6 staff, 1 witness, and complainant. LPA obtained and reviewed 3 staff medication training documents. LPA also reviewed 5 resident files. Interview with staff and witness revealed that COVID protocols were followed and staff/residents/visitors had temperature checks daily. Staff vaccination records were not available for review. However, staff stated that facility staff are either fully vaccinated or have exemptions.

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. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 4