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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 12:12:59 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
08/02/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220802110929
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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Eugenie Broussard, Executive Director
Marina Peckham, Staff		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility has a scabies outbreak
Staff did not seek medical treatment to resident's in care
INVESTIGATION FINDINGS:
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On 03/30/23 at 11:30M, ALicensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, gathered information and delivered investigation findings with executive director (ED). LPA explained the purpose of the visit with ED.

Allegation: Facility has a scabies outbreak
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, staff (S1) confirmed with LPA that facility had multiple scabies outbreaks in 2021 and 2022. Facility failed to adequately prevent the spread of scabies resulting in several residents and staff contracting it at various times. Staff (S1) stated that when residents were diagnosed with scabies, only the infected residents were treated and his/her beddings/clothing washed. 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: 03/30/2023
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 4
Control Number 15-AS-20220802110929
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: 03/30/2023
NARRATIVE
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No additional cleaning was done in common areas following scabies outbreaks. S1 also confirmed that residents' laundry were not being washed timely because there is only one laundry person left to do all the laundry. NOC shift staff are requested to help with the laundry. However, it is not done on a timely basis. 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 facility has a scabies outbreak was found to be substantiated.

Allegation: Staff did not seek medical treatment to resident in care
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, staff (S1) confirmed that resident (R1) is a high fall risk and has had several unwitnessed and witnessed falls (11/04/22, 11/25/22,11/26/22, 11/27/22) at the facility. On 11/25/22, witness (W1) stated that staff notified her of R1’s unwitnessed fall at 3:49PM and that they did not send him out to the hospital because he did not report any pain. On 11/26/22 at 2:34PM, W1 was notified by staff that R1 was sent out to the hospital because he was screaming in pain. R1 was diagnosed with a left greater trochanteric fracture which is non-operable. 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 did not seek medical treatment to resident in care 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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/02/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220802110929

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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Eugenie Broussard, Executive Director
Marina Peckham, Staff		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not infom authorized representatives change of residents medical condition
INVESTIGATION FINDINGS:
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On 03/30/23 at 11:30M, ALicensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, gathered information and delivered investigation findings with executive director (ED). LPA explained the purpose of the visit with ED.

Allegation: Staff did not inform authorized representatives change of resident’s medical condition
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, authorized representative (W1) stated that facility staff notified her whenever resident had an unwitnessed or witnessed fall and whenever R1 was sent out to the hospital for evaluation and treatment. Staff (S1) confirmed with LPA that they notified W1 by phone call of R1’s observed condition each time a reported incident occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that staff did not inform authorized representatives change of resident’s medical condition did occur, therefore the allegation is unsubstantiated.
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 4
Control Number 15-AS-20220802110929
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 A
03/30/2023
Section Cited
CCR
87470(b)
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when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2), assigned staff and volunteers, regardless of having direct contact with clients, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the communicable disease. …
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Deficiency corrected during visit.
ED hired additional laundry staff to properly manage residents clothing. ED also replaced washers and dryers to effectively prevent, contain and mitigate the transmission of infection.
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This requirement was not met as evidenced by scabies outbreaks at the facility which posed an immediate health & safety risk to residents in care
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ED agreed to complete and submit to CCL in-service staff retraining on infection control mitigation by 04/28/23.
Type B
04/28/2023
Section Cited
CCR
87465(a)(1)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents…
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By POC due date, ED agreed to submit to CCLD completed staff re-training in providing timely medical care appropriate to the conditions and needs of residents as well as on fall prevention protocols.
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This requirement was not met as evidenced by staff failing to timely send resident to the hospital when a incident occurred 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: 4 of 4