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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191501662
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:07:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240808160230
FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR:KEITH KASINFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: 62DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Desiree Eudave, Supervisor, Keith Kasin, AdministratorTIME COMPLETED:
03:19 PM
ALLEGATION(S):
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Staff do not have adequate staffing to meet resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent complaint visit to address the above allegation. LPAs met with Desiree Eudave, Supervisor and Keith Kasin, Administrator. LPA explained the reason for the visit.

08/16/2024 On this date, LPA interviewed six (6) staff six (6) residents from Assisted Living and LPA also obtained staff and resident roster and reviewed and obtained two (2) residents' relevant medical documentation, and current training documentation. LPA asked for R6 Woods discharge paperwork and updated LIC602 to be emailed and proof of emergency disaster training for night shift staff.

10/15/2024 LPA interviewed a total of ten (10) staff including staff previously interviewed on earlier visit. LPA interviewed one (1) additional resident. LPA interviewed six (6) residents total and LPA obtained R6 file and 08/2024 and 10/2024 staff schedule.

(Continued on 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240808160230

FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR:KEITH KASINFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: 61DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Desiree Eudave, Supervior and Keith Kasin, AdministratorTIME COMPLETED:
03:19 PM
ALLEGATION(S):
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Resident developed pressure injuries while in care.
Staff does not provide adequate supervision resulting in residents wandering away from facility.
Staff does not have proper training to administer medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent complaint visit to address the above allegations. LPAs met with Desiree Eudave, and Supervisor and Keith Kasin, Administrator. LPA explained the reason for the visit.

The investigation revealed:

Allegation: Resident developed pressure injuries while in care. It is alleged that 2 residents developed open wounds while in care.

LPA interviewed ten (10) staff and seven (7) of ten (10) staff stated they are aware of 2 residents with wounds but not sure if they developed in care. S2 stated that the two residents are currently on home health and that their wounds are stage 2. R6 stated R6 did not have wound when R6 arrived on December 1, 2023 and then she developed the wound on 02/2024. (continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240808160230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BRETHREN HILLCREST HOMES
FACILITY NUMBER: 191501662
VISIT DATE: 10/15/2024
NARRATIVE
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(Continued on 9099) Skill Nursing documentation paperwork dated 12/01/2023 shows R6 with wound which contradicts R6 statement. R1 arrived at facility with wound and currently both are getting Home Health services for their wounds. There is not enough evidence to substantiate this allegation.

Allegation: Staff does not provide adequate supervision resulting in residents wandering away from facility. It is alleged that residents have wandered off and put in harms way due to coyotes roaming around.

LPA interviewed ten (10) staff and eight (8) of (10 staff) denied the allegation. Six (6) of six (6) residents could not corroborate the allegation. There have been no reports of residents wandering off by local police or other authorities. There is not enough evidence to substantiate this allegation.


Allegation: Staff does not have proper training to administer medications. It is alleged that resident assistants that are not trained are administering medications during the overnight shift.

LPA interviewed ten (10) staff and nine (9) of 10 (ten) staff denied the allegation. LPA interviewed six (6) residents and six (6) of six (6) residents could not corroborate the allegations. S9 stated that only qualified staff has access to the medications so that cannot occur. S2 stated that only qualified staff are administering medications at facility.

Although the allegations may have happened or are 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 was conducted with and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240808160230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BRETHREN HILLCREST HOMES
FACILITY NUMBER: 191501662
VISIT DATE: 10/15/2024
NARRATIVE
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(continued from 9099)
Allegation: Staff do not have adequate staffing to meet resident's needs. It is alleged that facility does not have enough staff to meet resident's needs during the overnight shift. LPA interviewed ten (10) staff and seven (7) of ten (10) staff corroborated the allegation. LPA interviewed six (6) residents and five (5) of six (6) residents were able to corroborate the allegation. Some residents stated staff are very good but sometimes time a long time to assist them during the overnight shift. Some staff interviewed stated that the are stretched thin and have to leave some their assigned building and go to another building to administer medications or assist residents, leaving their assigned building without any staff during that time. Some staff stated that they will seek the assistance of the security guard to help out with resident's needs. Some staff agreed that overnight security guard assists then with residents at times. S2 and S9 also corroborated the allegation and stated security guard will assist staff with lifting residents who have falls overnight at times. Review of staff schedule for the month of August 2024 shows One (1) staff assigned to Birch court and one (1) staff assigned to Cedar court each day. The schedule for August 2024 also shows two (2) staff scheduled for Southwoods Memory care each day, one Med-tech (MT) and one resident Assistant (RA). The October 2024 schedule shows one (1) staff at Cedar court building for the overnight shift, one (1) staff at Birch Court and two (2) staff at memory care each night. The fact that staff have to seek the security guards assistance at times is evidence that facility does not have enough staff to meet the resident's needs during the overnight shift.

Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Supervisor Desiree Eudave along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240808160230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRETHREN HILLCREST HOMES
FACILITY NUMBER: 191501662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2024
Section Cited
CCR
87411(a)
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Personnel Requirements – General.
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
This requirement is not being met as evidenced by:
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Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements – General and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date which is 10/22/2024
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Overnight staff has had to seek the assistance of the security guard to assist residents due to lack of qualified staff.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5