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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:10:56 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
07/26/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220726093742
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:0CENSUS: 41DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Eugenie Broussard, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Insufficient staffing to meet residents' needs
Residents are not being fed in a timely manner
Staff did not provide laundry service in a timely manner
INVESTIGATION FINDINGS:
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On 10/05/23 at 4PM, 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’ roster, admission agreements, physicians reports, needs & services plans, housekeeping schedules, activities schedule, staff training records, incident reports.

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: 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 4
Control Number 15-AS-20220726093742
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: Insufficient staffing to meet residents needs
Investigation Finding: Substantiated
During investigation, the department interviewed staff (S1, S2) who stated that there was insufficient staffing during the periods of 04/01/2022 until 11/01/2022 due to termination of several care and housekeeping staff. S1 stated that remaining staff had to work extra shifts to meet residents’ needs that were not done in a timely manner. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of insufficient staffing to meet residents’ needs and found it to be substantiated.

Allegation: Residents are not being fed in a timely manner
Investigation Finding: Substantiated
During investigation, LPA interviewed staff (S1) who stated that due to insufficient staffing during the periods of 04/2022 until 11/2022, residents were not timely fed. S1 stated staff worked extra shifts to care for residents despite being short staffed. However, it was not done on a timely basis. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that residents are not being fed in a timely manner and found it to be substantiated.

Allegation: Staff did not provide laundry service in a timely manner
Investigation Finding: Substantiated
Based on interviews and record reviews which were conducted, staff (S1) confirmed with LPA that residents' laundry were not being washed timely because there was 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 staff did not provide laundry service in a timely manner was found to be substantiated.

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 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: 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 4
Control Number 15-AS-20220726093742
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
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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Deficiency corrected during visit.
New management hired additional staff to meet residents’ needs on 11/2022.
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This requirement was not met as evidenced by insufficient staffing which posed a potential health & safety risk to residents in care.
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Type B
10/05/2023
Section Cited
CCR
87555(b)(18)
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Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents…
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Deficiency corrected during visit.
New management hired additional staff to meet residents’ needs on 11/2022.
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This requirement was not met as evidenced by residents not being timely fed which posed a potential health & safety risk to residents 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: 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 4
Control Number 15-AS-20220726093742
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
87307(a)(3)(F)
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Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…(F) Basic laundry service (washing, drying, and ironing of personal clothing).
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Deficiency corrected during visit.
New management hired additional staff to meet residents’ needs on 11/2022.
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This requirement was not met as evidenced by staff not providing timely laundry service which posed a potential health & safety risk to residents 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: 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: 4 of 4