079200389-7-7-2021-15-AS-KHOS-C4VNUT-20210713104654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:11:55 PM

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
06/29/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210629153143

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	CECILY PALMA		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 50	DATE:	07/07/2021
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Cecily Palma, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Facility is in disrepair/damaged flooring

INVESTIGATION FINDINGS:

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On 07/07/21 at 1:07PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation of above allegation and met with administrator. LPA explained the purpose of the visit with administrator. LPA observed 3 staff wearing face masks. LPA observed front desk staff completed routine COVID-19 symptom checks (temperature check & questionnaire) and documented temperature/COVID-19 responses on visitor's log during visit.

During investigation, LPA observed 1st floor hallway flooring past the common TV area had several areas of broken planks and missing pieces which pose a safety hazard to residents, staff and visitors when walking in these areas. The preponderance of evidence has been met. Therefore, the above allegation is substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC 9099D. 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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210629153143

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: 07/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/30/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by first floor common hallway with several areas of broken/missing floor planks	1 2 3 4 5 6 7	Administrator agreed to repair first floor common area flooring and submit to CCLD on or before POC due date proof of correction (photos of repaired flooring).
	8 9 10 11 12 13 14	which posed a potential health & safety hazard to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

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