<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:15:20 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
07/08/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220708084748
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: 52DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Crystal Sheehan, Manager on DutyTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident hopsitalized due to sepsis, pneumonia, and dehydration
Facility failed to provide adequate care and supervision, resulting in resident sustaining pressure injuries while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/24 at 12:56PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with manager on duty (MOD) to deliver the finding of above allegation. LPA explained the purpose of the visit with MOD.

During investigation, the department obtained the following documents from administrator (ADM) – personnel record, residents’ roster, admission agreement, physicians report, Needs & services plans, weight record, activities of daily living schedule, hospital discharge summary 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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 5
Control Number 15-AS-20220708084748
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: 12/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Resident hospitalized due to sepsis, pneumonia and dehydration
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents and medical records. Review of R1’s records showed he was first admitted at the facility on 05/19/22, ambulatory, strong and able to brush his own teeth. On 07/01/22, R1 was transferred to hospital when R1 exhibited an altered state of consciousness; and was admitted and diagnosed with sepsis, pneumonia, acute kidney failure, unspecified protein calorie malnutrition, dementia, dehydration and stage 2 and 3 pressure injuries. Staff gave inconsistent statements of R1 being able to eat or drink liquids, and whether they had provided R1 with adequate liquids. Per interviews, staff stated that R1 was combative and that they had difficulty in providing care. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is Substantiated.

Allegation: Facility failed to provide adequate care and supervision, resulting in resident sustaining pressure injuries while in care
Investigation Finding: Substantiated
During investigation, the department reviewed resident’s (R1) medical records which showed R1 was transferred to the hospital on 07/03/22 and diagnosed with stage 2 and 3 pressure injuries. Interviews with facility staff and responsible parties, and review of facility documents showed facility failed to know about R1 sustaining pressure injuries while in care. Facility staff failed to conduct body checks, document any changes in condition and provide proper care to R1. Based on the department’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 failed to provide adequate care and supervision resulting in resident sustaining pressure injuries was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining pressure injuries while in care.

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 copy of report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/08/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220708084748

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: 52DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Crystal Sheehan, Manager on DutyTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident has lost a significant amount of weight
Resident's oral hygiene is not being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/24 at 12:56PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with manager on duty (MOD) to deliver the finding of above allegation. LPA explained the purpose of the visit with MOD.

Allegation: Resident has lost a significant amount of weight
Investigation Finding: Unsubstantiated
During investigation, the department reviewed resident’s (R1) documents which showed R1’s weight at 136 lbs 14.5 oz on 05/16/22. R1 was first admitted at the facility on 05/19/22. Witness (W1) documented R1’s weight on 07/01/22 at 135 lbs. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident has lost a significant amount of weight 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 resident lost a significant amount of weight is unsubstantiated. Continued on next page, LIC 9099-C pg1
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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 5
Control Number 15-AS-20220708084748
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: 12/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Resident’s oral hygiene is not being met
Investigation Finding: Unsubstantiated
During investigation, the department reviewed resident’s (R1) level of care assessment dated 05/19/22 R1 does not wear dentures and can self-manage his oral hygiene. Review of R1’s medical records showed no discussion related to the condition of R1’s oral hygiene. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident’s oral hygiene is 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.

Exit interview conducted 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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220708084748
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs…
1
2
3
4
5
6
7
By POC due date, administrator agreed to complete and submit in-service staff training on proper care and supervision of residents in compliance with Title 22 Section 87468.
8
9
10
11
12
13
14
This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining pressure injuries while in care.
Type B
12/30/2024
Section Cited
CCR
87466
1
2
3
4
5
6
7
When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person…
1
2
3
4
5
6
7
By POC due date, administrator agreed to complete and submit in-service staff training on proper observation of resident in compliance with Title 22 Section 87466.
8
9
10
11
12
13
14
This requirement was not met as evidenced by staff failing to address resident’s change in condition which posed a potential health & safety risk to residents 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5