079200389-10-5-2023-15-AS-KHOS-CWFSA7-20231009134152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:47:47 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
03/11/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220311121909

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	JARRETT SUELL		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	0	CENSUS: 41	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eugenie Broussard, Executive Director Marina Peckham, Resident Care Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not assist residents with self-administration medication as prescribed

INVESTIGATION FINDINGS:

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On 10/05/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with adminstrator (ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator - staff roster, residents admission agreements, physicians reports, residents’ roster, ID/Emergency information, centrally stored medication logs and medication administration records.

Continued on next page, LIC 9099-C

Unsubstantiated

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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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-20220311121909

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: 10/05/2023

NARRATIVE

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Allegation: Facility did not assist residents with self-administration medication as prescribed
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed R1's centrally stored medication logs and medication administration records dated 11/2021 until 12/2022. LPA observed R1 was prescribed medications by 3 different doctors and prescriptions were filled by Omnicare & Gateway pharmacies. Medications prescribed to R1 did not include psychotropic medication Xyprexa. However, LPA observed R1 was prescribed psychotropic medication Risperidone and anxiety medication Lorazepam by a different doctor. Review of medication administration records dated 09/01/2020 until 12/30/22 show staff (RCD, S1, S2) administered the medications as prescribed to R1.

LPA reviewed R2's centrally stored medication logs and medication administration records dated 11/2021 thru 01/2023. R2 was prescribed medications by 4 doctors and prescriptions were filled by Omnicare and Gateway pharmacies. R2 was prescribed Clozapine medications by her doctor and filled by the pharmacy from 11/15/2021 with expiration dates of 12/20/2022 and 01/27/2023. Review of medication administration records dated 09/01/2020 until 12/30/22 show staff (RCD, S1, S2) administered the medications as prescribed to R2.

LPA also interviewed residents (R1, R2) who confirmed they take their prescribed and over the counter medications daily from staff as ordered by their primary care physicians.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility did not assist residents with self-administration medication as prescribed and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility did not assist residents with self-administration medication is unsubstantiated.

No deficiency cited. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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