079200389-4-17-2023-15-AS-HHUL-CRVPLQ-20230516112506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 04/17/2023
Date Signed: 04/17/2023 01:40:46 PM

Unsubstantiated

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
10/05/2022 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20221005173114

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	DONNA BAUTISTA- COLMENARES		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 40	DATE:	04/17/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	EUGENIE BROUSSARD, Director		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff sexually abused resident

INVESTIGATION FINDINGS:

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On April, 17, 2023 at 01:05 pm Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegation. LPA met with Facility Supervisor Eugenie Broussard.

The Department’s investigation included but was not limited to interviews with current staff, witnesses, residents, and the collection and review of records from the facility.

Interviews with resident(R1) and staff (S1) revealed conflicting statements given by both individuals. R1 is partially blind, mentally fades memories from past to present, cannot feel below the waist and wheelchair bound. S1 has been employed since June 16, 2022. R1’s Activities of Daily Living (ADL) indicate, S1 assisted R1 with ADL at least 12 times from July 1, 2022 thru August 18, 2022 in which shower assistance was only provided 2 times ( 7/30/2022 and 7/31/2022).

Continused on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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-20221005173114

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: 04/17/2023

NARRATIVE

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...Continued from 9099

Based on interviews with S1 on 10/19/2022 at around 1136 hours, S1 admitted to providing assistance with R1 showering by cleaning R1 anal area and possibly touching R1’s private area unintentionally. S1 denied touching R1 inappropriately and/or sexually abusing R1. S1 is no longer providing care to the R1, and his position has changed from caregiver to laundry attendant; the change happened sometime in August 2022 or September 2022.

Based on interviews with R1 on 10/10/2022 at 1553 hours, R1 was unable to remember when S1 inappropriately touched R1 but reported the incident to staff 2 (S2) and staff 3 (S3) on 10/4/2022 and 10/5/2022. R1 could not state the duration of the incident. In a follow up interview on 10/13/2022, at approximately 1220 hours, R1 clarified that during the shower he felt a "release" of "fluid and pee”. R1 has left side paralysis and mentally "goes past to present" with his thoughts.

On 10/17/2022 the department obtained the surveillance video for 10/3/2022. The video surveillance was one hour, and 27 minutes long and only captures movement in the hallway. At 0328 hours, S1 is seen walking in through the end of the hallway door and walking down the hall to the laundry room. R1's room is the last bedroom on the left-hand side, closest to the elevator. S1 was seen multiple times walking back and forth throughout the hallway. S1 was not seen entering R1's room and was last seen at 2137 hours exiting through the end of hallway door.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC9099 (FAS) - (06/04)

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