079200389-7-13-2023-15-AS-HHUL-CUYVWN-20230823164813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 07/13/2023
Date Signed: 07/13/2023 10:22:29 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
12/12/2022 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20221212111529

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: 43	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Eugenie Broussard, Facility Supervisor		TIME COMPLETED:	10:38 AM

ALLEGATION(S):

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Due to lack of supervision, resident hit other resident while in care
Facility staff not assisting with incontinence care

INVESTIGATION FINDINGS:

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On July,13, 2023 at 09:25 am 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.

Allegation: Facility staff not assisting with incontinence care
Finding: SUBSTANTIATED

Interviews with W1 reviled that R1 was covered in feces when he went to Kaiser Permanente Emergency Room (ER). R1’s clinical notes state he was “covered in feces and having soiled feet.” These notes also stated that they were informed by the facility that R1 “is combative with staff who are trying to care for him and R1 attempts use the bathroom independently. But cannot successfully clean himself”
Continued on 9099C...

Substantiated

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: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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-20221212111529

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: 07/13/2023

NARRATIVE

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... Continued from 9099
The preponderance of evidence standard has been met; therefore, the above allegation(s) were found to be substantiated.

Allegation: Due to lack of supervision, resident hit other resident while in care
Finding: SUBSTANTIATED

On December 11, 2022, resident (R1) was transported to the hospital with a chief complaint of assault and battery. R1 was assaulted by another resident (R2) and sustained scratches to his neck and forehead, laceration on his left elbow, and avulsed left third toenail injury. R1 was discharged back to the facility on December 12, 2022. Incidents reports obtained facility also indicated R1 was physically assaulted by R2 on December 11, 2022.

Interviews with staff revealed conflicting statements regarding where R2 physically assaulted R1. S4 believed that staff did not see R2 physically assault R1. Interviews with S4 indicated that R2 is agitated, aggressive, and will physically assault other male residents and has a history of being aggressive with staff. Records review showed that R2 had a history of aggressive behaviors that were documented in his physician’s report, pre appraisal and care notes.

The preponderance of evidence standard has been met; therefore, the above allegation(s) were found to be substantiated. As a result of R1 sustaining serious bodily injury, the violation warrants a civil penalty assessment. A $500.00 immediate civil penalty is assessed.

Deficiencies are 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, LIC421IM, and 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: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221212111529

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: 07/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.	1 2 3 4 5 6 7	Licensee agreed to conduct a training regarding incontinence care and submit a self-certification along with staff attendance roster to LPA by plan of correction date
	8 9 10 11 12 13 14	This requirement is not met as evidenced by the resident being covered in feces when he was admitted to the hospital.	8 9 10 11 12 13 14
07/20/2023 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	Licensees who accept and retain residents with dementia shall be responsible for ensuring ... resident’s physical, social, emotional, safety and health care needs as identified in his current appraisal.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	A $500.00 civil penalty is assessed on this day. A Non-Compliance Conference (NCC) will be scheduled.
	8 9 10 11 12 13 14	The facility did not have enough supervision which resulted in a resident sustained an injury by another resident and caused him to go to the hospital which poses an immediate health and safety risk to the persons in care	8 9 10 11 12 13 14

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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