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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 01/30/2025
Date Signed: 01/30/2025 02:33:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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 Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240222113909
FACILITY NAME:HILLCREST MEMORY CAREFACILITY NUMBER:
079201249
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 58DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marina Peckham, Administrator (ADM)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Residents sustained injuries due to lack of supervision
Resident fell out of wheelchair due to lack of supervision
Facility staff did not seek medical attention for resident
Facility staff hit resident on the hand
Facility staff ignored request for help from resident
Facility staff did not meet incontinence needs of residents
Facility staff did not receive the required on the job training
Facility staff did not provide activities for residents
INVESTIGATION FINDINGS:
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On 01/30/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from ADM – Personnel record, Residents roster, admission agreements, physician's reports, reappraisals/assessments, Needs/Services plans, ID/Emergency information, hospital discharge summary reports, Staff training records, resident activities schedules, incident reports.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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 15-AS-20240222113909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HILLCREST MEMORY CARE
FACILITY NUMBER: 079201249
VISIT DATE: 01/30/2025
NARRATIVE
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Allegation: Residents sustained injuries due to lack of supervision
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff and reviewed resident’s (R1) documents. R1 was first admitted at the facility on 05/02/23 with chronic left facial weakness due to a stroke in 1997 as well as chronic leg swelling. She has dysphagia, dementia and is totally assisted by staff with bathing, dressing, grooming, dental care, toileting, transfers, meals and dementia care. Review of R1’s progress care notes from 06/12/23 to 02/23/24 showed staff monitored R1’s changes in condition and sent her to the hospital for treatment and evaluation on 08/13/23, 08/27/23, 12/25/23 and 02/04/24. On 01/22/24, R1 was placed under hospice care. Staff stated that they followed R1’s hospice care plan and communicated frequently with R1’ hospice care team and responsible party about R1’s condition. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that residents sustained injuries due to lack of supervision is unsubstantiated.

Allegation: Resident fell out of wheelchair due to lack of supervision
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff and reviewed resident’s (R1) documents. LPA interviewed (S1) who stated that on 01/21/24 at around 1:37AM, R1 had an unwitnessed fall. R1 was found on the floor by caregivers during their 4X per shift status checks. R1 complained of head hurting with a large lump on her right temple. Staff contacted hospice nurse and ice was placed on the bump every 5 minutes until the swelling subsided. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident fell out of the wheelchair due to lack of supervision is unsubstantiated.

Continued on next page, LIC 9099-C1
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240222113909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HILLCREST MEMORY CARE
FACILITY NUMBER: 079201249
VISIT DATE: 01/30/2025
NARRATIVE
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Allegation: Facility did not seek medical attention for resident
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff and reviewed resident’s (R2) documents. LPA interviewed staff (S1) who stated that R2 was first admitted at the facility on 05/01/23 with dementia. Review of R2’s care notes dated 02/11/24 showed staff noticed R2 had a right “blood shot eye”. Staff stated R2 denied feeling any discomfort with her right eye. Staff continued to monitor R2’s right red eye, notified her primary care physician and responsible party. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility did not seek medical attention for resident is unsubstantiated.

Allegation: Facility staff hit resident on the hand
Investigation Finding: Unsubstantiated
During investigation, the department interviewed staff and reviewed resident’s (R3) documents. LPA interviewed staff (ED, S1) who stated that R3 was first admitted at the facility on 07/02/2018 with a diagnosis of dementia. Review of R3’ s physician’s report dated 06/13/23 showed R3 as ambulatory and having disruptive, combative behaviors. Staff denied hitting any resident’s hand when displaying agitated behaviors. On 02/23/24 at around 03:22AM, staff was able to redirect and calm R3 when she became very agitated during shift rounds. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility staff hit resident on the hand is unsubstantiated.

Continued on next page, LIC 9099-C2
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20240222113909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HILLCREST MEMORY CARE
FACILITY NUMBER: 079201249
VISIT DATE: 01/30/2025
NARRATIVE
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Allegation: Facility staff ignored request for help from resident
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, S1) who denied that staff ignore any resident’s’ request for help. Staff are trained to assist each resident with their activities of daily living such as toileting, grooming, dressing, incontinence care, meals and medication management. During unannounced visits on 02/23/24, 02/27/24 and 08/09/24 LPA observed staff assisting residents with medications, meals, snacks, recreational activities, pharmacy refills, doctors’ appointments. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff ignored request for help from resident is unsubstantiated.

Allegation: Facility staff did not meet incontinence needs of residents
Investigation Finding: Unsubstantiated
During investigation, staff (ED, S1) confirmed with LPA that they followed residents’ weekly shower schedules in the AM/PM shifts and assisted residents with their daily hygiene needs such as changing diapers, toileting, grooming and dressing activities. LPA also reviewed random residents’ care plans which showed staff provided daily assistance with bathing (2X or more per week), daily toileting (AM, PM), dressing (AM, bedtime), changing diapers (2X to 3X per shift or as needed), dental care & grooming (AM, PM). Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility staff did not meet incontinence needs of residents is unsubstantiated.

Continued on next page, LIC 9099-C3
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240222113909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HILLCREST MEMORY CARE
FACILITY NUMBER: 079201249
VISIT DATE: 01/30/2025
NARRATIVE
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Allegation: Facility staff did not receive the required on the job training
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed staff’s training records dated 03/2024 which showed staff completed 20 hours of annual training which included reporting requirements, observation of residents and how to address residents’ changes in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the staff did not receive the required on the job training and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not receive the required on the job training is unsubstantiated.

Allegation: Facility staff did not provide activities for residents
Investigation Finding: Unsubstantiated
During investigation, LPA observed residents have daily recreational activities managed by their activities director which includes music hours, exercise, games, crafts, arts, morning strolls, board games, bingo and ball toss. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility is not providing activities to residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility is not providing activities to residents is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5