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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200389
Report Date: 10/20/2021
Date Signed: 10/20/2021 03:45:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
079200389
ADMINISTRATOR:CECILY PALMAFACILITY TYPE:
740
ADDRESS:825 EAST 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 55DATE:
10/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Cecily Palma, Executive DirectorTIME COMPLETED:
05:35 PM
NARRATIVE
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On 10/20/21 at 3:15PM, while at the facility conducting a complaint investigation, Licensing Program Analyst (LPA) Daisy Panlilio discussed the medication error on resident (R1) with Executive Director.

On 10/15/2021 while reviewing Resident 1 (R1) Medication Administration Record (MAR) and hospital discharge summary, LPA L Fontanilla observed the following:

- Cephalexin (Keflex) first dose was given on 10/23/19 at 5pm; last dose was given on 10/28/19 at 12 noon

- Bactrim first dose was given on 10/27/19 at 5pm; last dose was given on 10/29/19

R1’s hospital discharge dated 10/26/19 indicates that the doctor prescribed R1 a new antibiotic, Bactrim. In addition, the doctor ordered to discontinue Keflex. R1’s MAR indicates R1 was given Keflex until noon of 10/28/19 while R1 was already taking Bactrim.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date 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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited

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(a) (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
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This requirement is not met as evidenced by: R1’s hospital discharge dated 10/26/19 indicates that the doctor prescribed R1 a new antibiotic, Bactrim. In addition, the doctor ordered to discontinue Keflex. R1’s MAR indicates R1 was given Keflex until noon of 10/28/19 while R1 was already taking Bactrim which poses a potential threat to the health and safety of resident in care.
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medication administration by an accredited vendor and will fully comply with Title 22 Section 87465 (a)(5) Indidental medical and dental care of residents

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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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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