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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 03/15/2023
Date Signed: 03/15/2023 05:45:59 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
05/24/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210524142609
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: 43DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident has scabies
Residents who are admitted are incompatible
Staff are unable to meet the needs of the residents
INVESTIGATION FINDINGS:
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On 03/15/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, gathered information and delivered investigation findings with executive director (ED). LPA explained the purpose of the visit with ED.

Allegation: Resident has scabies
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, facility had multiple scabies outbreaks in 2020 and 2021. Facility failed to adequately prevent the spread of scabies resulting in several residents and staff contracting it at various times. Staff (S1) stated that when residents were diagnosed with scabies, only the infected residents were treated and his/her beddings/clothing washed. No additional cleaning was done in common areas following scabies outbreaks. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident has scabies was found to be substantiated. Continued o next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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-20210524142609
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: 03/15/2023
NARRATIVE
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Allegation: Residents who are admitted are incompatible
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, ED confirmed with LPA that two residents (R1, R2) admitted 06/15/21 and 04/09/21 were not compatible with the community. LPA reviewed R1 & R2’s pre-placement appraisals which showed both residents were diagnosed with mental disorders. Review of R1 & R2’s incident reports dated 03/30/22, 7/14/22, 12/29/22, 01/20/23. 2/15/23, 2/21/23, 2/24/23 show both residents displayed verbal, physical and aggressive behaviors which risked the health and safety of residents and staff. R1 was sent to a psychiatric hospital for treatment on 01/20/23 and never returned. R2 has not paid the facility for basic services since 04/09/21. ED and the Ombudman are currently assisting R2 to safely relocate to another facility that would address her needs. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that residents who are admitted are incompatible was found to be substantiated.

Allegation: Staff are unable to meet the needs of the residents
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, LPA confirmed with staff (S1) that facility was short staffed from July 2021 until September 2021. S1 stated that during that time, facility was unable to assist residents in their activities of daily living (ADLs) due to short staffing. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are unable to meet the needs of the residents was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20210524142609
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: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2023
Section Cited
CCR
87470(a)(2)
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assigned staff and volunteers, regardless of having direct contact with clients, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the communicable disease…
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Executive Director corrected deficiency on 03/15/23. Executive Director has implemented infection control plans 01/04/23 with staff to mitigate the transmission of communicable disease.
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This requirement was not met as evidenced by staff failing to prevent the spread of scabies which posed an immediate health & safety risk to residents in care.
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Type B
03/15/2023
Section Cited
CCR
87455(a)(7)
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Acceptance or retention of residents by a facility shall be in accordance with the criteria specified in this article 8 and Section 87605, Health and Safety Protection (7) Persons…whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility …
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Executive Director corrected deficiency on 03/15/23. ED continues to closely monitor R2 with one on one supervision and work with the Ombudsman in safely relocating resident (R2).
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This requirement was not met as evidenced by incompatible residents admitted at the facility which posed a potential health & safety risk to residents 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20210524142609
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: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2023
Section Cited
CCR
87413(a)(1)
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In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks
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Executive Director corrected deficiency on 03/15/23. Current Personnel record (LIC500) show sufficient staffing on all shifts (AM, PM, NOC shifts).
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This requirement was not met as evidenced by insufficient staffing which posed a potential health & safety risk to residents 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 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
05/24/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210524142609

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: 43DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Residents are losing a large amount of weight
Food service is inadequate
Residents are not provided with medical care after a fall
INVESTIGATION FINDINGS:
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5
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On 03/15/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, gathered information and delivered investigation findings with executive director (ED). LPA explained the purpose of the visit with ED.

Allegation: Residents are losing a large amount of weight
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, staff (S1) stated that during the COVID pandemic, some positive residents lost weight due to the effects of COVID-19 (loss of appetite). Staff stated they encouraged residents to drink Ensure and eat snacks during this time. S1 stated residents recovered their appetite after their COVID symptoms cleared. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that residents are losing a large amount of weight did occur, therefore the allegation is unsubstantiated.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20210524142609
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: 03/15/2023
NARRATIVE
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Allegation: Food service is inadequate
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, staff (S3) stated residents were regularly served 3 meals a day (breakfast, lunch & dinner) daily with snacks and drinks available to residents. LPA was not able to confirm food service with residents due to dementia. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that food service is inadequate did occur, therefore the allegation is unsubstantiated.


Allegation: Residents are not provided with medical care after a fall
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, resident care director (RCD) stated incident reports are generated for falls. Review of incident reports dated 05/08/21, 08/05/21 & 08/13/21 show staff assisted residents by calling 911, notifying authorized representatives, residents’ primary care physicians and transporting residents to the hospital for evaluation and treatment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that residents are not provided with medical care after a fall did occur, therefore the allegation is unsubstantiated.

Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6