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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 05:05:46 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
05/10/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210510162846
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:
02:00 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident fell while in care sustaining minor injuries
INVESTIGATION FINDINGS:
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On 03/15/23 at 2PM, 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 fell while in care sustaining minor injuries
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, resident (R1) had an unwitnessed fall on 05/08/21 in the outside patio. Staff (S1) confirmed with LPA that due to high staff turnover and understaffing during this time, R1 were left unattended until 7PM when they called 911 and sent him to the hospital for treatment and evaluation.

Continued on next page, LIC 9909-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 5
Control Number 15-AS-20210510162846
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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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 fell while in care sustaining minor injuries was found to be substantiated.

Deficiency is 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 5
Control Number 15-AS-20210510162846
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
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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Executive Director corrected deficiency on 03/15/23.

Sufficient staff were hired in January/February 2023 and trained to assist residents in care.
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This requirement was not met as evidenced by insufficient staff 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 5
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
05/10/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210510162846

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:
02:00 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not meeting residents needs
Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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On 03/15/23 at 2PM, 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: Staff are not meeting residents’ needs
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, ED stated residents were visited by a certified podiatrist to address their feet needs. Staff (S1) could not confirm with LPA if R1’s nails were cut too short or not by the podiatrist. LPA could not confirm podiatrist 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 staff are not meeting residents’ needs 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: 4 of 5
Control Number 15-AS-20210510162846
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: Staff are mismanaging residents’ medication
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, staff administered resident’s (R1) medication according to his primary care physician’s (PCP) prescription orders which were filled by the hospital pharmacy. Review of R1’s centrally stored medication logs show R1 received his daily medications (AM, PM and Bedtime) as prescribed by his PCP. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that staff failed to provide recreational activities for residents 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: 5 of 5