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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002932
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:28:17 AM

Document Has Been Signed on 10/21/2024 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
455002932
ADMINISTRATOR/
DIRECTOR:		O'FARRELL, KEILAFACILITY TYPE:
740
ADDRESS:7 HILLTOP DRTELEPHONE:
(530) 395-1777
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 211CENSUS: 166DATE:
10/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Keila O'FarrellTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On October 21, 2024 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Management-Deficiencies inspection.

During the Case Management-Deficiencies inspection, LPA reviewed the LIC 602 for Resident #1. Based on a review of the LIC 602, LPA learned that the resident is not allowed to leave the facility unassisted. However, the resident eloped from the facility and was found 3 miles away at the Best Buy. LPA educated the Administrator on the importance of ensuring that safety measures are put in place to address the wandering/elopement of residents in care.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2024 11:28 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/21/2024 at 11:12 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HILLTOP SPRINGS SENIOR LIVING
FACILITY NUMBER: 455002932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2024
Section Cited
CCR
87705(b)(2)

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87705(b)(2) Care of Persons with Dementia:
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Administrator/Licensee shall conduct staff training and provide proof of training. In addition, facility shall submit an LIC 9098-Self Certication and a plan for future compliance.
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This requirement was not met as evidenced by:

Based on a review of the LIC 602, Resident #1 is unable to leave the facility unassisted which presents an immeidate health, safety and personal rights risk to the resident(s) in care.
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POC Due Date: 10/22/2024

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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:Lauren Crocker
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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