079200389-3-27-2025-15-AS-KHOS-DFHHXU-20250407063542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 03/27/2025
Date Signed: 03/27/2025 12:33:05 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
06/30/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220630164118

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: 59	DATE:	03/27/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jared Pickard, Executive Director/ADM Crystal Sheehan, Resident Care Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Questionable death
Facility did not ensure changes in resident’s condition were brought to the attention of a physician in a timely manner
Facility did not ensure changes in resident’s condition were brought to the attention of resident's responsible person in a timely manner

INVESTIGATION FINDINGS:

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On 03/27/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, pre-placement appraisal, admission agreement, physicians reports, infection control mitigation plan, incident reports.

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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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-20220630164118

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: 03/27/2025

NARRATIVE

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Allegation: Questionable death
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff (ADM, RCC, S1) and responsible party (RP) and reviewed resident’s (R1) documents. Staff (ADM, RCD, S1) stated R1 tested positive for COVID-19 on 06/10/22. ADM stated staff notified responsible parties of the outbreak, communicated with public health, quarantined positive residents, and implemented COVID-19 mitigation plan.
RCD stated when R1 was diagnosed positive with COVID-19, she was able to communicate if she is not feeling well, was able to walk, eat and drink on her own. ADM stated that R1 did not show signs of being ill, no cough and did not have trouble breathing. S1 stated that R1 was independent, active, could change her own clothes and eat by herself until her passing on 06/15/22. No information emerged that R1 passed away specifically due to staff failing to provide need. The department interviewed staff (ADM, RCD, S1) and all stated R1 presented as normal and no symptoms were noted up to expiration. Review of R1’s death certificate showed main cause of death was COVID-19 with contributing factors of dementia and depression. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of questionable death 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 of questionable death is unsubstantiated.

Continued on next page, LIC 9099-C pg2

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220630164118

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: 03/27/2025

NARRATIVE

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Allegation: Facility did not ensure changes in resident’s condition were brought to the attention of a physician in a timely manner
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff and responsible party (RP) and reviewed resident’s (R1) documents. S1 stated that on 06/15/22 staff observed R1 to be her normal self (depressed and sleeping a lot) with no indications that R1 required medical attention. S1 stated R1 was provided lunch at noon in her room and was observed sleeping. RP stated that on 06/15/22 at 1400 hours, S1 informed him that R1 was not breathing & unresponsive and that they have contacted 911. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility did not ensure changes in resident’s condition were brought to the attention of a physician in a timely manner 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 ensure changes in resident’s condition were brought to the attention of a physician in a timely manner 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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20220630164118

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: 03/27/2025

NARRATIVE

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Allegation: Facility did not ensure changes in resident’s condition were brought to the attention of resident’s responsible person in a timely manner
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff and responsible party (RP) and reviewed resident’s (R1) documents. RP stated that ADM contacted him the first week of June 2022 and advised him of the COVID-19 outbreak at the facility. ADM stated R1 tested positive for COVID-19 on 06/10/22 and notified RP of R1’s positive test result on the same day. On 06/13/22, RP stated he had a Zoom call with R1 and observed her as confused, happy, tired and her breathing was “okay’. RP stated that he was not notified of any change in R1’s condition or R1’s positive COVID-19 status until 06/15/22. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility did not ensure changes in resident’s condition were brought to the attention of resident’s responsible person in a timely manner 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 did not ensure changes in resident’s condition were brought to the attention of resident’s responsible person in a timely manner is unsubstantiated.

No deficiency cited during visit.

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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

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