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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 03/30/2023
Date Signed: 03/30/2023 11:24:03 AM

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
12/24/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211224091106
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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eugenie Broussard, Administrator
Marina Peckham, Staff		TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained injury while in care
INVESTIGATION FINDINGS:
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On 03/30/23 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver investigation findings and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Resident sustained injury while in care
Investigation Finding: Substantiated
On 12/30/21, the Department interviewed the staff (ADM, S1) who stated that ambulatory resident (R1) mainly stays at the facility and loves to wander around. Witness (W1) stated she observed R1's bandaged right knee during a visit on 12/23/21. Staff (ADM, S1) stated they do not know how or when R1 sustained the injury at the facility. Based on records review, interviews conducted and observations made, the Department has investigated the above allegation and found that it is substantiated. A finding that the complaint allegation is substantiated means that there is a preponderance of evidence to prove the alleged violation that resident sustained injuries while in care did occur.

Deficiency is 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

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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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 3
Control Number 15-AS-20211224091106
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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
87468,2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Deficiency corrected during visit
ADM hired additional staff in January and February 2023 to provide care and supervision to residents.
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This requirement was not met as evidenced by resident sustaining injury while in care which posed a potential health & 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
12/24/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211224091106

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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eugenie Broussard, Executive Director
Marina Peckham, Resident Care Director		TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
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8
9
Facility staff do not communicate to authorized representative
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/30/23 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver investigation findings and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Facility staff do not communicate to authorized representative
Investigation Finding: Unsubstantiated
On 12/30/21, the Department reviewed R1’s incident reports dated 11/09/21 and 12/25/21. Both incident reports show R1’s authorized representative (POA) was notified by staff (S1) of each occurrence. Based on records review, interviews conducted and observations made, the Department has investigated the above allegation and found that it is unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that facility staff do not communicate to authorized representative did occur.

Exit interview conducted and a copy of this report provided.
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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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 3