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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191501662
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:57:59 AM

Unsubstantiated


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
03/25/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210325122412
FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR:MATTHEW NEELEYFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lynn Palin TIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Resident sustained an unwitnessed fall resulting in a broken bone.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent visit to deliver the findings for the above allegation. LPA met with MSW Lynn Palin and explained the reason of the visit.

The investigation consisted of the following: On 04/01/21, LPA Almaraz interviewed Fairley. The following documents were requested; staff and resident roster, staffing schedules for the months of 11/2020 and 01/2021, documentation on registry staff usage from 12/2020 -03/2021, communication staff logs for 1/2020 and internal investigation report for Resident #1 conducted by the facility. LPA also requested files for Residents #1-3. On 10/15/2021 LPA Alvarez and Mora interviewed Matthew Neeley and Sue Fairley. LPA requested staff and resident roster, and additional documents. On 6/14/22, LPA Wong and Bennette interviewed the director of Social work, CEO of Hillcrest, four residents from Assisted Living and two residents from Memory Care unit and LPA also obtained staff and resident roster and reviewed two residents' medication from Memory Care Unit.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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
Control Number 28-AS-20210325122412
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: 01/13/2023
NARRATIVE
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The investigation revealed of the following: In regard to the allegation of “Resident sustained an witnessed fall resulting in a broken bone.” All staff denied the allegation and reported staff found R1 was in a kneeling position in the side of the bed and R1 did not want to get up, staff gave R1 time and came back and saw R1 was on the floor scooting to the restroom. Staff also reported R1 often slept partially off the bed, so it was not particularly unusual to see R1 kneeling by the bed. R1 was also able to ambulate for a full day following when the staff found R1 kneeling by the bed and witnessed R1 scooting to the restroom.

Based on the interviews conducted with staff and residents and record review, Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the complaint investigation of the allegations are all UNSUBSTANTIATED.

An Exit Interview was conducted. The copy of the report and appeal right were provided to MSW Lynn Palin
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
03/25/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20210325122412

FACILITY NAME:BRETHREN HILLCREST HOMESFACILITY NUMBER:
191501662
ADMINISTRATOR:MATTHEW NEELEYFACILITY TYPE:
741
ADDRESS:2705 MOUNTAIN VIEW DRIVETELEPHONE:
(909) 593-4917
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:574CENSUS: DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lynn Palin TIME COMPLETED:
12:20 PM
ALLEGATION(S):
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9
Staff did not seek resident timely medical attention.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Christine Wong conducted a subsequent visit to deliver the findings for the above allegations. LPA met with MSW Lynn Palin and explained the reason of the visit.

The investigation consisted of the following: On 04/01/21, LPA Almaraz interviewed Fairley. The following documents were requested; staff and resident roster, staffing schedules for the months of 11/2020 and 01/2021, documentation on registry staff usage from 12/2020 -03/2021, communication staff logs for 1/2020 and internal investigation report for Resident #1 conducted by the facility. LPA also requested files for Residents #1-3. On 10/15/2021 LPA Alvarez and Mora interviewed Matthew Neeley and Sue Fairley. LPA requested staff and resident roster, and additional documents. On 6/14/22, LPA Wong and Bennette interviewed the director of Social work, CEO of Hillcrest, four residents from Assisted Living and two residents from Memory Care unit and LPA also obtained staff and resident roster and reviewed two residents' medication from Memory Care Unit.
(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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 5
Control Number 28-AS-20210325122412
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: 01/13/2023
NARRATIVE
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The investigation revealed of the following: In Regard to the allegation “Staff did not seek resident timely medical attention.” It was reported that staff did a visual body assessment when R1 fell but no documentation on the communication log or generate any incident report or notify any family or upper management about R1’s fall because staff reported it was not uncommon for R1 to feel pain. The next staff from next shift also reported that was nothing was reported regarding R1’s pain or fell. Although once R1 complained of pain, facility nurse did the assessment again for R1 and initialed called to the doctor to order the X-ray and they read the result and immediately sent R1 to ER.

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 MSW Lynn Palin along with the Appeals Rights.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210325122412
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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance ...........and the resident's responsible person, if any.
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The administrator will ensure the staff would ensure residents are regularly observed for changes in physical, mental, emotional and social functioning and Administrator will retrain staff on the regulation about observation of resident and sent the training log to LPA by POC due date.
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The requirement was not met as evidenced by LPA's interview and recorded review
It was repored that R1 was complaint of pain and staff did not report or notify any family or upper management about R1’s fall which posed a potenital risk for 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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5