079200389-10-5-2023-15-AS-KHOS-CWNS4A-20231016133226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:31:32 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
04/21/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220421172455

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:	0	CENSUS: 41	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Eugienie Broussard, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility did not prevent residents from getting scabies

INVESTIGATION FINDINGS:

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On 10/05/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (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 – personnel record, residents admission agreements, physicians reports, residents’ roster, Needs & services plans, housekeeping schedules, activities schedule, staff training records, pest control records.

Continued on next page, LIC 9099-C

Substantiated

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)

Page: 1 of 7

Control Number 15-AS-20220421172455

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 prevent residents from getting scabies
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 hot water washed. No additional cleaning was done in common areas following scabies outbreaks. S1 also confirmed that residents' laundry were not being hot water washed timely because there is only one laundry person left to do all the laundry. NOC shift staff were requested to help with the laundry. However, it was 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.

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 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)

Page: 2 of 7

Control Number 15-AS-20220421172455

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: 10/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/05/2023 Section Cited CCR 87470(b)(A)	1 2 3 4 5 6 7	The licensee shall consult with a medical professional, local health official, health department, or other research-based medical authority to determine the type of enhanced environmental cleaning based on the contagious disease in the facility…	1 2 3 4 5 6 7	Deficiency corrected on 11/01/22. New management hired additional staff to implement proper infection control in compliance with Title 22 Section 87470 regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the outbreak of scabies due to lack of staff for infection control which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
04/21/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220421172455

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:	0	CENSUS: 41	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Eugienie Broussard, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not properly trained
Facility has insects
Facility is dirty
Resident's hygiene needs are not being met
Facility is not providing activities to resident's
Facility management is not available to resident's

INVESTIGATION FINDINGS:

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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)

Page: 4 of 7

Control Number 15-AS-20220421172455

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: Staff are not properly trained
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed staff’s training records dated 03/2022 which showed staff completed 20 hours of annual training which included reporting requirements, observation of residents and how to address residents’ changes in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the staff are not properly trained 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 staff are not properly trained is unsubstantiated.

Allegation: Facility has insects
Investigation Finding: Unsubstantiated
During investigation, LPA did not observe the presence of vermin (cockroaches, ants, rats) at the facility during unannounced visits on 03/01/22, 03/16/22 and 04/07/22. Staff (ADM) stated that facility has an annual contract with a pest control company that inspects and eliminates pests every quarter or as needed. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility has insects 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 facility has insects is unsubstantiated

Continued on next page, LIC 9099-C pg3

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)

Page: 5 of 7

Control Number 15-AS-20220421172455

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 is dirty
Investigation Finding: Unsubstantiated
During investigation, LPA conducted an unannounced visit on 04/29/22 and observed flooring on the 1st floor was replaced with new flooring. Walls and common areas were observed clean and odor free. LPA inspected 3 rooms on the first floor and 2 rooms on the second floor. Bedroom and bathroom walls were observed clean (no feces) and odor free. Staff (MD) stated common areas are cleaned daily. Housekeeping staff clean residents’ apartments according to the weekly schedules. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility is dirty 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 facility is dirty is unsubstantiated.

Allegation: Residents’ hygiene needs are not being met
Investigation Finding: Unsubstantiated
During investigation, LPA observed residents to be clean and odor free during unannounced visits on 04/29/22, 04/07/22, 03/01/22. Staff confirmed with LPA that they followed residents’ weekly shower schedules in the AM/ PM shifts and assisted residents with their hygiene needs such as toileting, grooming and dressing activities. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that residents’ hygiene needs are not being met 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 residents’ hygiene needs are not being met is unsubstantiated.

Continued on next page, LIC 9099-C pg4

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)

Page: 6 of 7

Control Number 15-AS-20220421172455

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 is not providing activities to residents
Investigation Finding: Unsubstantiated
During investigation, LPA observed residents have daily recreational activities managed by their activities director which includes music hours, exercise, games, crafts, arts, morning strolls, board games, bingo and ball toss. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility is not providing activities to residents 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 facility is not providing activities to residents is unsubstantiated.

Allegation: Facility management is not available to residents
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (S1) who stated that there was a change in management on 03/01/22. S1 stated staff work in 3 shifts which include AM, PM & NOC shifts. Each shift has one med tech and 3 to 4 caregivers on duty. Staff stated they assist residents with their activities of daily living such as toileting, grooming, dressing, meals and medication management. During unannounced visits on 04/29/22, 04/07/22, 03/01/22, LPA observed staff assisting residents with medications, meals, recreational activities and snacks. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility management is not available to residents 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 facility management is not available to residents is unsubstantiated.

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)

Page: 7 of 7