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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 08/09/2024
Date Signed: 08/09/2024 01:04:20 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
02/26/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240226115617
FACILITY NAME:HILLCREST MEMORY CAREFACILITY NUMBER:
079201249
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 60DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marina Peckham, Administrator
Crystal Sheehan, Staff		TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff are provoking resident
Staff did not allow resident to have his cigarettes
INVESTIGATION FINDINGS:
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On 08/09/24 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, admission agreements, physicians reports, needs & services plans, physicians’ orders, medication administration records, narrative charting notes, incident reports, staff training certifications.

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: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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 7
Control Number 15-AS-20240226115617
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
FACILITY NUMBER: 079201249
VISIT DATE: 08/09/2024
NARRATIVE
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Allegation: Staff handled resident in a rough manner
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED) who confirmed that staff (S2) had an inappropriate physical interaction with resident (R1) during an incident that occurred on 02/25/24 between 7PM and 9PM. Review of video footage recorded during the incident on 02/25/24 showed S2 had inappropriate physical interaction with 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 staff handled resident in a rough manner was found to be substantiated.

Allegation: Staff are provoking resident
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (S1) who confirmed that staff (S2) provoked resident (R1) during an incident that occurred on 02/25/24 when S2 refused to give R1 his request for extra juice and to have his cigarettes. Review of video footage recorded incident dated 02/25/24 showed R1 and S2 engaged in a physical/verbal altercation in the activities area. 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 staff are provoking resident was found to be substantiated.

Continued on next page, LIC 9099-C1
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20240226115617
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
FACILITY NUMBER: 079201249
VISIT DATE: 08/09/2024
NARRATIVE
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Allegation: Staff did not allow resident to have his cigarettes
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED, S1) who confirmed that staff (S2) provoked resident (R1) during an incident that occurred on 02/25/24 by not allowing him to have his cigarettes. Review of video footage recorded during the incident on 02/25/24 showed S2 engaged in a physical/verbal altercation with R1 and did not allow R1 to have his cigarettes. 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 staff did not allow resident to have his cigarettes 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 copy of report provided.

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

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/26/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240226115617

FACILITY NAME:HILLCREST MEMORY CAREFACILITY NUMBER:
079201249
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 60DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marina Peckham, Administrator
Crystal Sheehan, Staff		TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/09/24 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, admission agreements, physicians reports, needs & services plans, physicians’ orders, medication administration records, narrative charting notes, incident reports, staff training certifications.

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: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20240226115617
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
FACILITY NUMBER: 079201249
VISIT DATE: 08/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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16
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Allegation: Staff are mismanaging residents’ medication
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed residents (R1, R2, R3, R4) who stated that staff assisted them with their medications daily. Review of centrally stored medication logs and medication administration records showed staff assisted residents with their daily medications as prescribed by their primary care physicians (PCP). Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are mismanaging residents’ medication and found it to be unsubstantiated. 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 staff are mismanaging residents’ medication was found to be unsubstantiated.

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: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20240226115617
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
FACILITY NUMBER: 079201249
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
CCR
87468.1(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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By POC due date, Administrator agreed to submit completed in-service retraining of all staff on residents’ personal rights in compliance with Title 22 Section 87468.1 regulations.
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This requirement was not met as evidenced by staff handling resident in a rough manner which posed a potential health & safety risk to residents in care.
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Type B
08/30/2024
Section Cited
CCR
87468.2(a)(4)
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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.
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By POC due date, Administrator agreed to submit completed in-service retraining of all staff on personal rights in compliance with Title 22 Section 87468.2 regulations.
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This requirement was not met as evidenced by staff provoking resident 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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20240226115617
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
FACILITY NUMBER: 079201249
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
CCR
87468.2(a)(3)
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To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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By POC due date, Administrator agreed to submit completed in-service retraining of all staff on personal rights in compliance with Title 22 Section 87468.1 regulations.
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This requirement was not met as evidenced by staff did not allow resident to have his cigarettes 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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7