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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 10/20/2021
Date Signed: 10/20/2021 03:49:49 PM



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
11/04/2019 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20191104144000
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
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cecily Palma, Executive DirectorTIME COMPLETED:
04:54 PM
ALLEGATION(S):
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Facility staff failed to administer medication to resident as prescribed
INVESTIGATION FINDINGS:
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On 10/20/21 at 2:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit to deliver the investigation findings and met with Executive Director (ED). LPA explained the purpose of the visit with ED.

LPA L. Fontanilla reviewed the following records for R1: Medication Administration Record (MAR) for October and November 2019, hospital discharge and incident report.
ON 10/26/2019, incident report submitted to CCL indicate that R1 was observed by 2 staff clawing and hitting his head in bed. R1 was sent to Kaiser Emergency Department and was prescribed Bactrim(Antibiotic) and Banophen(itching or rash). A review of the MAR indicates that R1 completed the Bactrim doses. However, there is no record observed in October and November 2019 MARs to show that Banophen was given to R1. Therefore, the above allegation is substantiated.

Based on record review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D
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: 10/20/2021
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20191104144000
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: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited
CCR
87465(a)(5)
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(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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Administrator agreed that all staff assisting residents with medication will undergo 2 hours of training on Section 87465 Incidental Medical and Dental Care of Title 22
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This requirement is not met as evidenced by: On 10/26/19, R1 was observed by staff clawing, was sent to the hospital and prescribed Bactrim and Banophen. Based on October and November 2019 MARs, facility failed to assist R1 with Banophen which poses a potential threat to the health and safety of R1.
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and submit proof of training to CCLD on or before POC due date
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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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
11/04/2019 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20191104144000

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
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cecily Palma, Executive DirectorTIME COMPLETED:
04:54 PM
ALLEGATION(S):
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Facility staff failed to meet resident's needs
Facility staff left resident in soiled clothing for an extended period of time
Resident sustained unexplained injuries while in care
Facility staff failed to provide adequate food for resident
Facility has an insect infestation
Facility failed to meet laundry needs
Facility is in disrepair
INVESTIGATION FINDINGS:
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On 10/20/21 at 2:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit to deliver the investigation findings and met with Executive Director (ED). LPA explained the purpose of the visit with ED.

Allegation: Facility staff failed to meet resident's needs
On October 18, 2021, LPA L. Fontanilla reviewed R1’s assessment and Physician’s Report (PR). PR indicates R1 is able to feed self independently. The assessment signed by R1’s responsible person indicates that R1 must be fed as needed. In regards to incontinence care management, staff interviewed state that residents who need incontinence care are being checked regularly. S2 states that staff observe residents for nonverbal cues that maybe a sign that residents need assistance in going to the toilet. S2 also added that staff monitor incontinent residents’ food and water intake. S2 states that staff take residents to the bathroom as frequent as possible especially after mealtimes and before bedtime.
Based on LPA Singh’s interview with S2, staff get training from Relias. S2 added that video trainings with paper tests are done on a monthly basis. In-service trainings from outside vendors are conducted as needed.

Continued on next page, LIC 9099-C
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: 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.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20191104144000
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: 10/20/2021
NARRATIVE
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Allegation: Facility staff left resident in soiled clothing for an extended period of time

On 11/7/2019, LPA Praveen Singh interviewed S2 and S4. S2 states that staff take residents who need incontinence care to the toilet as frequent as possible especially after meals and before bedtime. Staff also monitor residents’ food and water consumption. Staff observe for nonverbal cues that may indicate resident’s need to go to the toilet. S2 added that staff get training on a monthly basis. S4 states that each staff is provided with a plan of care for each resident. S4 states that incontinent residents get checked every hour and changed, if needed. S4 added that there should not be any resident left with feces for long hours since staff check/change resident regularly.

Allegation: Resident sustained unexplained injuries while in care

On 10/18/2021, LPA L. Fontanilla reviewed the following records for R1: Physician’s Report and Initial Move in assessment both dated 3/26/2019, hospital discharge summary and incident reports (SIR).

Based on Physician’s Report and assessment, R1 is ambulatory, has wandering behavior and is independent with mobility and able to independently transfer to and from bed. A review of the incident reports and hospital discharge received indicate that R1 was sent out to the hospital numerous times for the month of October 2019 for different reasons. On October 17, R1 was seen at the Emergency Department (ED) due to a “head injury that does not appear serious” at the time of visit. On October 22-23, R1 was treated in the hospital and prescribed antibiotic. On October 26, R1 was seen at the ED and prescribed a different antibiotic and medicine for rash or itching.

On 11/20/2019, one resident pushed R1 which caused R1 to hit head on the wall. Based on incident report, R1 was clapping repeatedly which agitated the other resident.

Both residents were sent to the hospital. R1 returned to the facility with no changes in medication while the other resident was admitted for further evaluation due to aggression.

Continued on next page, LIC 9099-C

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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20191104144000
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: 10/20/2021
NARRATIVE
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Allegation: Facility staff failed to provide adequate food for resident

On 10/14/2021, LPA L. Fontanilla obtained a copy of menu for the month of November 2019 signed by a dietitian. LPA also reviewed R1’s Physician’s Report to verify R1’s move in weight. LPA referred to a previous report dated 5/23/2019 indicating R1’s weight. Based on records, R1’s move in weight is 136 lbs. On 5/23/2019, R1 weighed 153 lbs. R1’s weight record for June 2020 indicates R1’s weight is 165 lbs.

Based on weight records reviewed, R1 has gained weight since moving to the facility. However, the weight gain is not sufficient proof that R1 is getting adequate food.

Allegation: Facility has an insect infestation

Based on interview with S2 conducted by LPA Praveen Singh on 11/7/2019, 2 rooms were infected with bedbugs but were treated three times then cleared. On 10/14/21, LPA L. Fontanilla obtained a copy of the facility’s contract with Zap Termite and Pest Control. The contract is dated 12/1/2015 and states that the company will provide pest control services to the facility on a monthly basis.

On 10/14/2021, Executive Director confirmed with LPA L. Fontanilla that the pest control company has been providing pest control services to the facility on a monthly basis since 2015.

Allegation: Facility failed to meet laundry needs

On 11/7/2019, LPA Praveen Singh interviewed S1, S2 and S4 regarding laundry services.

Based on interviews conducted, residents have laundry schedules on a weekly or as needed basis. Staff interviewed state that residents who need incontinence care get their clothes washed right away. And the staff do not wait until the end of the day to wash incontinence laundry.

On 10/14/2021, LPA obtained a copy of the facility’s weekly laundry schedule which indicates R1’s schedule on Sunday. LPA interviewed Executive Director regarding laundry schedule. Director states that laundry service is provided to residents once a week or as needed. For soiled clothes out of schedule, Director states that staff wash soiled clothes immediately.

Continued on next page, LIC 9099-C

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
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20191104144000
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: 10/20/2021
NARRATIVE
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Allegation: Facility is in disrepair

On 11/7/2019, LPA Praveen Singh conducted an inspection of the kitchen. Based on LPA Singh’s report, facility has sufficient supply of foods and there were no leaks or broken appliances observed. LPA Singh also indicated that she inspected corners and did not observe any insect or rodent droppings. She also interviewed S3 who states that facility has not have any rodent or mold problems.

On 10/11/2021, LPA Luisa Fontanilla interviewed S3 regarding the above allegation. S3 states that the kitchen is regularly cleaned and disinfected by staff daily. S3 added that every 3 months, the grease trap gets cleaned by SRC Pumping. There is a possibility that during the cleaning process, there is a smell that comes off but it is unavoidable. Otherwise, S3 denied that the kitchen smells like a sewer pipe. Invoice obtained indicate grease trap cleaning was conducted on 11/15/2019.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of this report provided to ED.

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
LIC9099 (FAS) - (06/04)
Page: 6 of 6