<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002932
Report Date: 07/29/2026
Date Signed: 07/29/2026 03:03:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2026 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20260518082320
FACILITY NAME:HILLTOP SPRINGS SENIOR LIVINGFACILITY NUMBER:
455002932
ADMINISTRATOR:LEHNER, TRACYFACILITY TYPE:
740
ADDRESS:7 HILLTOP DRTELEPHONE:
(530) 395-1777
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:211CENSUS: 94DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Memory Care Director Waniesha OrtizTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not ensure facility has sufficient staffing to meet the care needs of residents
Staff do not ensure residents receive clean linens for their beds
Staff do not ensure residents call buttons are answered promptly
Staff do not ensure residents take their medications once dispensed
Staff do not ensure residents rooms are kept clean
Staff do not ensure residents receive bathing assistance
Facility is charging for services not provided to residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On July 29 2026 licening program analyst LPA Sarah Benson arrived at the facility unannounced to deliver complaint findings. LPA Benson met with Memory Care Director Waniesha Ortiz and explained the purpose of the visit. LPA Benson toured the facility and did staff interviews.

During the investigation interviews were conducted, four staff persons and four residents were interviewed. The following documents were received and reviewed: staff list and phone number, staff schedule, admission agreement, care plan, call button records, cleaning records, laundry records, MAR and shower logs.


Continued on LIC9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
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 5
Control Number 59-AS-20260518082320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HILLTOP SPRINGS SENIOR LIVING
FACILITY NUMBER: 455002932
VISIT DATE: 07/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The allegation: Staff do not ensure residents rooms are kept clean and trash is not removed from their rooms promptly.

During staff interviews, S1 stated the care staff will take out the garbage daily as needed. S1 stated we have talked about getting a covered garbage cans when depends are used. S2 stated I have witnessed a room not up to standard, when I have done a room check. S2 stated when this happens, I call care staff back to the room to clean it. S2 stated staff are required to take out the garbage per shift, it there is a smell or something soiled it is taken care of immediately. S3 stated when a resident has a pet it is the responsibility of the resident or family to take care of the pets needs. S3 stated some residents hire private care givers to take care of the pets. S3 stated I don’t usually see the wet pee pads on the floor. S4 stated the resident’s rooms always tend to be clean, we have house keepers and I do the dishes or clean up messes. S4 stated at times the garbage can be overflowing when I come in the morning shift, because the previous shift didn’t take them out. S4 stated some residents are independent with toileting and by the morning have a few depends in the garbage.


During resident interviews R1 stated my room is kept clean, it’s fine. R2 stated I do my own dusting, staff clean the bathroom and kitchen, floors and they take out the garbage. R3 stated It’s ok, I have no complaints. R4 stated the room is cleaned once a week. R4 stated I have been on their case about taking out the garbage. R4 stated the staff changes the depends then leaves the dirty depends in the room to stink up the room.
Record review of residents service plan states that staff will remove trash every shift, with weekly bed change and weekly laundry service every Thursday.
LPAs’ observation during the inspection and interviews LPA Benson observed (4) four residents’ rooms that were tidy, clean and trash was emptied. Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20260518082320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HILLTOP SPRINGS SENIOR LIVING
FACILITY NUMBER: 455002932
VISIT DATE: 07/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The allegation: Staff do not ensure residents receive bathing assistance
During staff interviews, S2 stated staff are required to ask about getting a shower, if they refuse we get a change of face, three times. S3 stated it is ADL routine; we have protocol for shower refusals. S3 states the clients have the right to have family assist. S4 stated our shower log can be messed up as the residents will switch their shower days and or refuses the shower. S4 stated the residents family often gives the resident her shower.
During resident interviews Resident one R1 stated I don’t get my shower here, my daughter has a beautiful house they take me there for that.
During LPA record review LPA observed a shower log with the resident scheduled for shower assist on Tuesdays and Fridays.
LPA record review of resident shower logs for three months revealed twice on 4-24-26 and 5-8-26 a note stating, “not shower day”. Staff stated at least twice maybe more, when I went to shower the resident she had already had been given a shower by her daughter. Unsubstantiated.

The allegation: family provide services they are paying the facility to perform, including shower assistance, changing bedding and laundry.
During staff interviews, S1 stated laundry is provided, one load of laundry and one load of towels weekly. S1 stated housekeeping, laundry and rides are part of the rent. S2 stated the service chart stating the laundry schedule is in the charting room on the first floor. S2 stated we will change bedding and wash as often as needed. Staff stated R1 may need a higher level of care.
The administrator stated all assisted living residents receive weekly housekeeping services including weekly laundry ,bed change and rides as part of the rental agreement with no extra charge. The administrator stated it is the responsibility of the residents to put the clean bedding out so staff won’t have to look through the residents belonging for the clean bedding. caregivers are responsible for that and are supposed to go to the resident’s rooms to do checks at least once a day.
LPA observed four out of four residents’ rooms to be clean and orderly, the garbage was taken out.
LPAs record review revealed resident receives weekly housekeeping, trash, vacuum, tidy, dusting and bed making. The residents care plan states weekly housekeeping along with weekly bed change, all trash removed every shift.
Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20260518082320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HILLTOP SPRINGS SENIOR LIVING
FACILITY NUMBER: 455002932
VISIT DATE: 07/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The allegation: residents are brought to the dining hall late even after pressing their call buttons, and staff take a long time to respond to call buttons.
During staff interviews, S2 stated we try to get to the call lights as soon as we can. S2 stated if we are assisting a resident then we will reach out to other staff for assistance. S2 states we have one care staff on each floor. S2 stated and one med tech on floor one with one med tech covering floor two and three. S2 stated we have staff have a tablet, that shows who pushed the call button first. S2 stated we help in order of when the button was pushed. S2 stated staff get to know the residents that want to go to dinner early. S3 stated we currently try to get to residents quickly; we may be assisting a resident that takes a longer time. S4 stated it differs every day as to who I work with.
During resident interviews Resident one R1 stated I don't have a problem with that, I don’t push my button. R2 stated anytime I push my button things are fine. R2 stated staff show up, it isn’t within minutes, but it is fine,
During file review LPA Benson received a copy of the third-floor pendant alarm call request/response record. LPA observed the said resident did not push their pendant from April 28 to May 22 2026. LPA’s record review revealed the majority of calls of neighbors were answered in less than eight minutes with the longest response time as twenty four minutes. Unsubstantiated.

The allegation: Staff do not ensure residents take their medications once dispensed.
During staff interviews, Staff stated I do not let residents take their medication with them, I must watch the residents take the medication. Staff stated I tell the resident that I can take the medication to them if they want to take their medication a little later. Staff stated I believe it is in our training videos that the resident needs to take the medication when given. It was reported some of our residents take care of their own medication. Staff reported it is not protocol to let a resident wait to take their medication after we administer it. Staff stated I have not found any misplaced medication.
During resident interviews R1 stated, I didn’t find a pill. R2 stated staff take care of my medication. Resident reported, staff always stay right here and make sure I take my medication. Resident four R4 stated I have observed staff don’t leave until my partner takes their medication. Unsubstantiated.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20260518082320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HILLTOP SPRINGS SENIOR LIVING
FACILITY NUMBER: 455002932
VISIT DATE: 07/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The allegation: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents
During resident interviews a resident stated I recommend them, they take care of everything. A resident stated that anytime I push my button things are fine. Another resident stated my care needs are met for sure
During staff interviews, staff stated at least twice maybe more, when I went to shower the resident she had already been given a shower by her daughter.
LPA record review revealed the residents care plan states the resident request help with bathing, requesting staff nearby in apartment for time-to-time assistance and safety issues. Record review of service plan states that staff will remove trash every shift, with weekly bed change and laundry cleaned on Thursday’s.
LPAs’ observation during the inspection and interviews LPA Benson observed (4) four out of four residents’ trash emptied and clean rooms. Unsubstantiated.

The allegation: Staff do not ensure residents receive clean linens for their beds
During staff interviews, Staff reported once a week housekeepers change the linens on the bed, residents are asked to leave sheets out so staff won’t have to riffle through the residents’ belongings. Staff stated if bedding is soiled the care giver is responsible to change the bedding. Staff stated I am the follow up, if a family member or resident says my bed didn’t get changed then I will make sure it gets done. S2 stated we have a chart on the wall in the charting room on the first floor. Staff reported the charts often get messed up, when family or residents change laundry or shower days. S2 stated we pull the bedding when a shower is done and laundry is done on a separate day. S2 stated each resident has a service plan. S3 stated It is in the routine, to make sure the beds are clean. S3 stated If the resident only has one set of sheets, we ask the family to bring more. Staff stated it is our responsibility to make sure the linens are changed and there are serious consequences if we don’t do it.
During resident interviews resident one R1 stated if I don’t pee on the bed then my little dog does. R1 stated my family comes and helps change the pee mats on the floor and takes my dog for walks. Resident three R3 stated they are not right on top of that, maybe two weeks will go by without changing my sheets. R3 stated they are supposed to do it automatically, I’m not sure what to do. During interviews the majority of residents reported the beding is changed weekly or sooner.
Record review of service plan states that staff will remove trash every shift, with weekly bed change and laundry. Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5