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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:08:26 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
10/06/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221006104119
FACILITY NAME:HILLCREST MEMORY CARE LIVINGFACILITY NUMBER:
079200389
ADMINISTRATOR:DONNA BAUTISTA- COLMENARESFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 44DATE:
03/06/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Eugenie Broussard, Administrator and Marina Peckham, Resident Care DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not adequately trained.
Washer and dryer is in disrepair.
Staff did not administer medication to resident.
INVESTIGATION FINDINGS:
1
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5
6
7
8
9
10
11
12
13
At 11:00 AM on 03/06/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings for the above allegations. LPA met with Administrator (ADM) Eugenie Broussard and Resident Care Director (RCD) Marina Peckham to explain the reason for the visit.

During the investigation, LPA made observations, reviewed records, and interviewed staff. Significant data collected concerning the allegations above include:

ALLEGATION: Staff are not adequately trained: Staff S1, S5, S7, and S8 reported the inadequacy of not only their initial training, but also their on-the-job training, to enable them to adequately support them in doing their work.

ALLEGATION: Washer and dryer is in disrepair: LPA observed notation on a non-functioning dryer that it had not been working for more than two (2) months (since 08/08/2022), which was confirmed by staff S6.

REPORT CONTINUES ON 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
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 6
Control Number 15-AS-20221006104119
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: 03/06/2023
NARRATIVE
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REPORT CONTINUED FROM 9099

ALLEGATION: Staff did not administer medication to resident. Staff S1, S5, S7, and S8 all stated that medications were frequently not administered. LPA reviewed medication administration records for six (6) residents (R4, R5, R6, R7, R8, and R9) between 04/01/2022 and 10/14/2022. During that time, a total of 120 medication doses were reported as not having been administered to those residents.

Based on the data collected over the course of the investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be 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 via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
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
10/06/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221006104119

FACILITY NAME:HILLCREST MEMORY CARE LIVINGFACILITY NUMBER:
079200389
ADMINISTRATOR:DONNA BAUTISTA- COLMENARESFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 44DATE:
03/06/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Eugenie Broussard, Administrator and Marina Peckham, Resident Care DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent an outbreak of the Norovirus.
Staff are not following food safe handling protocols.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 11:00 AM on 03/06/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings for the above allegations. LPA met with Administrator (ADM) Eugenie Broussard and Resident Care Director (RCD) Marina Peckham to explain the reason for the visit.

During the investigation, LPA made observations, reviewed records, and interviewed staff. Significant data collected concerning the allegations above include:

ALLEGATION: Staff did not prevent an outbreak of the Norovirus. Neither review of the records nor interviews indicated that staff caused a Norovirus outbreak.

ALLEGATION: Staff are not following food safe handling protocols. No interviews nor record reviews indicated that staff were not following safe food-handling protocols.

REPORT CONTINUES ON 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20221006104119
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: 03/06/2023
NARRATIVE
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CONTINUED FROM 1099-A

Based on the data collected during the course of this investigation, 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. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20221006104119
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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2023
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Completed during visit.
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Based on staff interviews and records reviews, Licensee failed to administer medications according to the physician's directions or at all, such as residents R4, R5, R6, R7, R8, and R9 who had a total of 120 doses not administered between 04/01/2022 and 10/14/2023, which poses an immediate health and safety risk to resident in care.
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Type B
03/13/2023
Section Cited
CCR
87411(d)
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87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance

This requirement is not met as evidenced by:
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Completed during visit.
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LPA interviews of staff S1, S5, S7, and S8 who reported the inadequacy of not only their initial training, but also their on-the-job training, to enable them in adequately doing their work, which poses an potential health and safety risk to resident 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: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20221006104119
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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2023
Section Cited
CCR
87303(a)(3)(F)
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87307 Personal Accommodations and Services (a) Living accommodations ... provide comfortable living accommodations ... for the residents ... (3) Equipment ... necessary for personal care ... the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing).
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Completed during visit.
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This requirement was not met as evidenced by:

LPA observed that 1 of 4 dryers had not been in operation since 08/08/2022, which poses a potential health and safety risk to resident 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: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6