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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 06:14:21 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
12/07/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20221207163118
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: 43DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
05:54 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Staff failed to assist resident in purchasing personal items
INVESTIGATION FINDINGS:
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On 03/15/23 at 6PM, 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 failed to assist resident in purchasing personal items
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, authorized representative (W1) confirmed that resident (R1) is conserved and receives monthly funds for his personal and incidental (P & I) needs. W1 stated that R1 has torn/worn out clothing and former facility director claimed that R1 had no funds for clothing. Review of R1’s monthly P & I dated 12/08/22 show he had sufficient funds for purchasing clothing and other personal items. 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 failed to assist resident in purchasing personal items was found to be substantiated. Continued on 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 5
Control Number 15-AS-20221207163118
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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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
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
12/07/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20221207163118

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: 43DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
05:54 PM
MET WITH:Eugenie Broussard, Executive DirectorTIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Staff are financially abusing resident in care
Staff failed to provide recreational activities for residents
INVESTIGATION FINDINGS:
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On 03/15/23 at 6PM, 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 financially abusing resident in care
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, resident (R1) is conserved and facility receives monthly personal and incidental funds P & I) from conservator. Review of R1’s P & I show monthly funds were received, deposited into R1’s account and recorded. LPA confirmed with current ED that R1’s funds are available for him to use for personal purchases. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that staff is financially abusing resident in care 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: 3 of 5
Control Number 15-AS-20221207163118
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 failed to provide recreational activities for residents
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, LPA observed residents have daily recreational activities managed by their activities director which includes music hours, exercise, games, crafts, arts, morning strolls, board games, bingo and ball toss. 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: 4 of 5
Control Number 15-AS-20221207163118
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
87705(b)
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In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia…
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Administrator corrected deficiency on 12/09/22.
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This requirement was not met as evidenced by staff failing to assist resident in purchasing personal items which posed a potential health & safety risk to resident in care
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Staff assists R1 in purchasing personal items and proper monthly accounting of R1’s Personal and Incidental (P & I) records are provided to his conservator.
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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: 5 of 5