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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002932
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:11:20 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
02/22/2024 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20240222082958
FACILITY NAME:HILLTOP SPRINGS SENIOR LIVINGFACILITY NUMBER:
455002932
ADMINISTRATOR:PURKEY, SIMEONFACILITY TYPE:
740
ADDRESS:7 HILLTOP DRTELEPHONE:
(503) 391-9999
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:211CENSUS: 72DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Heather Newcom General ManagerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not ensure that residents' medications are disposed of from the facility.
Staff do not store residents' medications locked and inaccessible to residents.
Staff do not conduct audits of residents' narcotic medications.

INVESTIGATION FINDINGS:
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On 4-25-24 at 3:45PM, Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 02/22/24. LPA Benson met with Heather Newcom General Manager, Susan Mosby Health Service Manager, Lacey Mcdermoth Resident Care Cordinatior and explained the purpose of the visit.

Continued on 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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 2
Control Number 59-AS-20240222082958
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: 04/25/2024
NARRATIVE
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Staff do not ensure that residents' medications are disposed of from the facility.

During the interview process, documents were obtained to include the medication room audit, MAR/Narcotics weekly audit for five weeks and the centrally stored medications destruction document.

During the investigation process, the administrator, the resident care coordinator and three staff persons related to the medication room were interviewed. In addition, LPA Boyles toured the medications room for a medication review with the administrator and the resident care coordinator. LPA Boyles reported that she observed the medications that were waiting to be destroyed. The administrator reported that sometimes there is a delay in destroying medication because as their policy states, two nurses must be present. The administrator reported that sometimes due to competing demands, medication destruction is not prioritized and is rescheduled. However, medication is destroyed within the parameters outlined within the program plan.

Staff do not store residents' medications locked and inaccessible to residents.

During the investigation process, the administrator, the resident care coordinator and three staff persons related to the medication room were interviewed. In addition, LPA Boyles toured the medications room for a medication review with the administrator and the resident care coordinator. It was reported by LPA Boyles that all medications were locked and inaccessible to residents. During the interview process none of the persons interviewed indicated that they have seen medications unlocked.


Staff do not conduct audits of residents’ narcotic medications.

During the investigation process all staff indicated that the residents’ narcotic medications are audited daily with a two-person review. In addition, documents were received of the medication room audit and MAR/Narcotics weekly audit for five weeks. During the interviews and documents reviewed, there was no indication that staff do not conduct audits of residents narcotic medications.

Although the above allegations mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and all of the above findings are Unsubstantiated.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2