306005871-7-30-2026-22-AS-SSAS-DWHT2A-20260731142026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005871
Report Date: 07/30/2026
Date Signed: 07/30/2026 05:54:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/31/2025 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20251231083634

FACILITY NAME:	HILLCREST SENIOR LIVING		FACILITY NUMBER:	306005871
ADMINISTRATOR:	ALVARADO, MARY JEAN		FACILITY TYPE:	740
ADDRESS:	6468 CALLE DEL NORTE		TELEPHONE:	(714) 749-7237
CITY:	ANAHEIM HILLS	STATE: CA	ZIP CODE:	92807
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2026
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Mary Alvarado		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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staff did not ensure adequate supervision was provided to resident in care resulting in resident’s death
Staff did not ensure medication records were properly managed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Mary Alvarado and explained the reason for the visit.

During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated November 17, 2025, R1’s Hospice records dated December 1 through 28, 2025, R1’s Death Certificate, Facility Death report dated December 28, 2025, R1’s Appraisal/Needs and Services Plan dated November 17, 2025, and R1’s Admission Agreement dated November 22, 2025.

The investigation into the allegation, staff did not ensure adequate supervision was provided to resident in care resulting in resident’s death, revealed the following.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

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 22-AS-20251231083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
	VISIT DATE: 07/30/2026

NARRATIVE

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Hospice Nurse 2 reported that if they ever suspected facility staff from neglecting or causing or contributing to someone’s death, they would report it. R1’s responsible party reported that they were called on December 25, 2025, about R1’s condition and on December 28, 2025, they were called so they went to visit R1. R1’s responsible party reported they were present when R1 passed away and didn’t recall specific details about the care that was provided to R1 on that day. R1’s responsible party reported that they never witnessed any actions by staff that were abusive or that could have led to R1’s death. Hospice Nurse 2 reported they don’t remember any issues with R1 or the facility that would be a cause for concern. Hospice Nurse 1 reported that they never witnessed any issues or had a cause of concern for R1 or the facility. Hospice Nurse 1 reported that they don’t believe anything the staff did contributed to the death of R1. Staff 2 (S2) was present at the facility when R1 passed away but reported they were caring for the other residents and weren’t involved with R1’s care that day. S1 reported that after Hospice arrived, they handled all of R1’s care needs. Hospice Nurse 1 verified this information. R1’s death certificate lists R1’s cause of death as Alzheimer’s Disease with Late Onset, on December 28, 2025, at 5:20 pm. No other contributing factors are listed. Hospice records for R1 dated December 18, 2025, state, “Over the past 15 days, the patient has exhibited a continuous and progressive decline in condition, consistent with the terminal trajectory of their end-stage disease.” None of the evidence gathered supports the allegation.

Based on the evidence gathered through interviews and documents reviewed the allegation is deemed unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff did not ensure medication records were properly managed, revealed the following. It was reported that R1’s medication records were not properly recorded and documented. R1’s physician ordered R1’s medications to be crushed because of R1’s difficulty with swallowing. A review of records show R1 had routine medications and PRN medications (as needed) and a Hospice comfort kit of medications administered by Hospice Nurses stored at the facility including Morphine 20ml solution. A review of Hospice records show R1 was prescribed a total of 24 medications. Facility records show R1 was prescribed a total of 24 medications. Staff 1 and Staff 2 reported that R1’s medication records were current and reflected all of the medications they were prescribed. At the time of the initial 10-day visit (December 31, 2025) R1's medications were no longer at the facility and had been returned to the pharmacy, so R1's medications could not be inventoried.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 22-AS-20251231083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
	VISIT DATE: 07/30/2026

NARRATIVE

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It was reported that facility staff administered medications to R1 on December 24, 2025, and that staff caused R1 to vomit on December 25, 2025, which led to the death of R1. It was reported that R1 began to decline because of these actions which eventually led to R1’s death on December 28, 2025. R1 moved into the facility on November 22, 2025. According to R1’s physician’s report dated November 17, 2025, R1 was diagnosed with Alzheimer’s Disease late onset. R1 moved into the facility under Hospice care. R1 was provided with Hospice care almost daily. A review of medication records shows R1 received their routine medications for December 1 through 24, 2025, except for Triamcinolone Acetonide ointment 0.1%. Staff 1 and Staff 2 reported that after December 24 R1 could not take medication. Hospice Nurse 1 and Hospice Nurse 2 reported that they only administered liquid morphine to R1 after December 24, 2025, as R1 could no longer take medication except in liquid form. A review of records shows On December 25, 2025, Staff 1 (S1) reported that R1 was unresponsive and had vomited. S1 did not recall what time the incident took place. S1 reported that they cleaned R1 and called hospice. S1 did not recall how they cleaned R1’s mouth and why R1 had vomited. LPA interviewed Hospice Nurse 1 who cared for R1 on December 25 and December 28, 2025. Hospice Nurse 1 reported that R1 was having difficulty breathing and they administered oxygen. A review of hospice records for December 25, 2025, verified this information. No other issues were noted for R1 during the Hospice visit on December 25, 2025. No other incidents or issues were noted for R1 until December 28, 2025. On December 28, 2025, S1 reported that R1 was unresponsive and had labored breathing so Hospice was called. S1 reported they did not remember what time they called hospice. Hospice Nurse 1 responded to the call and assessed R1. Due to R1’s condition S1 requested that R1 receive continuous hospice care. Hospice Nurse 1 agreed and continuous Hospice care was approved for R1. Hospice Nurse 1 reported they do not remember what time they arrived at the facility. LPA interviewed Hospice Nurse 3 who completes the Hospice record notes. Hospice Nurse 3 reported that the only exact time on the hospice notes is the time of death because that is recorded and communicated immediately. The Hospice notes recorded are not exact times and are the times entered when the notes are completed not when the nurse arrives or when the facility calls. Hospice Nurse 3 reported that they complete the notes and don’t provide care to residents and don’t do facility visits, so the time on the daily notes are not necessarily accurate. Hospice Nurse 1 reported that they continued to provide care to R1 until they were relieved at 4:00 pm by Hospice Nurse 2. Hospice Nurse 2 reported they did not recall December 28, 2025, as they made numerous visits that day for people who were actively passing. Hospice Nurse 2 reported that their job is to make the residents as comfortable as possible and to help with a peaceful transition.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 22-AS-20251231083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
	VISIT DATE: 07/30/2026

NARRATIVE

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R1 was prescribed Triamcinolone Acetonide Ointment 0.1 % topical, for a wound that was discovered on their back around December 12, 2025. The medication was prescribed on December 15, 2025. The wound was not staged/classified and R1 was noted to be stable with no issues. The order for the medication instructed the ointment to be applied twice a day until resolved. A review of R1’s medication records shows that R1 was administered all their other routine medications but the entries for Triamcinolone Acetonide Ointment 0.1 % topical for December 1 through December 28, 2025, are all blank showing there is no record of it being administered. Staff 1 and Staff 2 could not explain why the medication administration record for Triamcinolone Acetonide Ointment 0.1 % topical was blank. Staff 1 and Staff 2 could not recall if Triamcinolone Acetonide Ointment 0.1 % topical was administered to R1. There is no evidence that R1 received their prescribed Triamcinolone Acetonide Ointment 0.1 % topical. Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 22-AS-20251231083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
	VISIT DATE: 07/30/2026

NARRATIVE

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LPA reviewed R1’s medication records and they were kept in accordance with Title 22 California Code of Regulation (CCR) 87465. All medications administered by Hospice are listed on their visit reports and a copy was kept with R1’s records. No discrepancies were observed with the listing of R1's prescribed medications. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Administrator, and a copy of the report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/31/2025 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20251231083634

FACILITY NAME:	HILLCREST SENIOR LIVING		FACILITY NUMBER:	306005871
ADMINISTRATOR:	ALVARADO, MARY JEAN		FACILITY TYPE:	740
ADDRESS:	6468 CALLE DEL NORTE		TELEPHONE:	(714) 749-7237
CITY:	ANAHEIM HILLS	STATE:CA	ZIP CODE:	92807
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2026
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Mary Alvarado		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff did not ensure medications were dispensed as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Mary Alvarado and explained the reason for the visit.

During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated November 17, 2025, R1’s Hospice records dated December 1 through 28, 2025, R1’s Death Certificate, Facility Death report dated December 28, 2025, R1’s Appraisal/Needs and Services Plan dated November 17, 2025, and R1’s Admission Agreement dated November 22, 2025.

The investigation into the allegation, staff did not ensure medications were dispensed as prescribed, revealed the following.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 22-AS-20251231083634

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLCREST SENIOR LIVING	FACILITY NUMBER: 306005871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/31/2026 Section Cited CCR 87468.1(a)(16)	1 2 3 4 5 6 7	To receive or reject medical care or other services. This requirement was not met as evidenced by, R1 did not receive their prescribed routine medication, Triamcinolone Acetonide Ointment 0.1 % topical, which poses an immediate health, safety and personal rights risk to residents in care.	1 2 3 4 5 6 7	Licensee agrees to train staff on CCR 87468.1 and sign a statement of understanding for CCR 87468.1. Proof of correction to be submitted to the LPA by the POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 7