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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002932
Report Date: 03/04/2025
Date Signed: 03/04/2025 09:48:59 AM

Substantiated


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
08/13/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240813110806
FACILITY NAME:HILLTOP SPRINGS SENIOR LIVINGFACILITY NUMBER:
455002932
ADMINISTRATOR:O'FARRELL, KEILAFACILITY TYPE:
740
ADDRESS:7 HILLTOP DRTELEPHONE:
(530) 395-1777
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:211CENSUS: 172DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:KEILA O'FARRELLTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff are not adequately trained to meet resident needs.
Staff do not respond to resident’s call for assistance in a timely manner.
Staff do not ensure resident’s toileting needs are met.
Staff do not keep facility clean and sanitary.
Facility call system is in disrepair.
INVESTIGATION FINDINGS:
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On 03/04/25 Donna Gurriere and Kayla Adkison, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/13/24. LPA Gurriere met with Keila O’Farrell, Administrator and explained the purpose of the visit.

Staff are not adequately trained to meet resident needs.

During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. In addition, records were obtained. Residents were not interviewed due to their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers

continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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 9
Control Number 59-AS-20240813110806
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2025
Section Cited
CCR
87707(2)(B)
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Training Requirements - Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period… Training may be provided at the facility or offsite and may include a combination of observation and practical application.
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The administrator agrees to submit an understanding of the regulation. In addition, the administrator agrees to advise the licensing agency what the facility’s standard is for hours that the staff persons will be trained before being let go to work on their own.
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This requirement was not met as evidenced by: Based on interviews the Licensee/ Administrator did not ensure that staff had adequate training to meet the needs of the residents. This poses a potential hazard to residents in care.
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Type B
03/11/2025
Section Cited
CCR
87411(a)
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Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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The administrator agrees to submit an understanding of the regulation. The administrator agrees to provide a statement on how they will meet the staffing to resident ratio.
Repeat Violation $250. civil penalty.
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This requirement was not met as evidenced by: Based on interviews, the Licensee/ Administrator could not respond to residents in a timely manner due to being understaffed. This poses a potential hazard to residents in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 59-AS-20240813110806
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: 03/04/2025
NARRATIVE
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During the investigation process, on 09/24/24 LPA Sarangi interviewed staff persons and they reported that they had the video training that met the licensing training requirements. During the month of October 2024, the staff were interviewed by LPA Gurriere and nearly all felt that they did not have sufficient training while working on the floor as a “care provider or as a medication technician.” Staff reported that they had one to three days of training on the floor shadowing another care provider before they were to provide care and supervision to the dementia residents in memory care on their own. Staff reported that they did not agree that their time training on the floor was adequate.

Substantiated.


Staff do not respond to resident’s call for assistance in a timely manner.

During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. In addition, records were obtained. Residents were not interviewed due to their dementia status.

During the investigative process, most staff reported that the memory care unit is understaffed and cannot provide aid in a timely manner. It was stated that the staffing for the memory care unit was one care provider and one med technician per shift, (three separate shifts) to provide care and supervision for dementia residents. During LPA Gurriere’s visit on 10/08/24 it was confirmed that there was one care provider and one med technician for 13 dementia residents. It was stated that if the care provider is changing a resident in the resident’s room and the med technician is in the med room preparing medications, there is no one else in the common area to provide care and supervision to the residents.

Substantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 59-AS-20240813110806
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: 03/04/2025
NARRATIVE
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Staff do not ensure resident’s toileting needs are met.

During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers.

During the investigation process, it was reported that the resident (Resident 1) was found by the resident’s family member and two staff persons that started their shift, laying in urine and feces. In addition, the resident’s bedsheets were soaked and soiled. It was reported that the resident was in this state and that it was believed that the nighttime shift did not check or change the resident in a timely manner. It was reported that staff try to check on the resident’s toileting needs every two hours; however, when asked for the toileting/incontinence log, it was reported by the administrator that there was none.

Substantiated.


Staff do not keep facility clean and sanitary.

During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status.

During the investigation process, it was reported that the memory care unit did not have a housekeeper to provide cleaning for approximately one month, due to the housekeeper leaving. It was reported that during that time, there was a lack of cleaning in resident rooms. It was stated that the staffing for the memory care unit was one care provider and one med technician per shift, (three separate shifts) to provide care and supervision for dementia residents. It was stated that a housekeeper may clean intermittently, and that staff are to clean in between when the housekeeper does not clean. Staff reported that for each shift, the care provider and the med tech were to provide housekeeping, laundry, food serving, incontinent care, showering, care and supervision, and passing of medications.

Substantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 59-AS-20240813110806
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2025
Section Cited
CCR
87625(b)(2)
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Managed Incontinence - In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
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The administrator agrees to develop an incontinence log to ensure that all staff are being accountable in checking on residents’ incontinence during the daytime and the nighttime. The administrator shall submit a blank copy of the log to the licensing agency. The administrator agrees to train staff on how to use the log.
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This requirement was not met as evidenced by: Based on interviews, the Licensee/Administrator did not ensure that a resident was checked for incontinence. This poses a potential hazard to residents in care.
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Type B
03/11/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The administrator agrees to submit to the licensing agency the LIC 500 Personnel Report indicating the staffing schedule for the memory care unit. In addition, the Personnel Report shall address staffing names, days, and times the staff will work in the memory care unit.
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This requirement was not met as evidenced by: Based on interviews, the Licensee/
Administrator did not ensure that a housekeeper was present to ensure that the facility was clean and sanitary. This poses a potential hazard to residents in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 59-AS-20240813110806
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: 03/04/2025
NARRATIVE
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Facility call system is in disrepair.

During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers.

During the investigation process, it was reported that at times the call system and the necklace call button did not work. It was reported that recently, a call system on the wall fell off the wall, a call for one room rang in a different room rather than the original room and that there is not always a good reception service to ensure that staff are being notified of a call.

Substantiated.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore all of the above allegations are found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 59-AS-20240813110806
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2025
Section Cited
CCR
87303(i)(1)(A)
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Maintenance and Operation - Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Operate from each resident's living unit.
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The administrator agrees to have the call system inspected by a professional and shall send the invoice to the licensing agency.
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This requirement was not met as evidenced by: Based on interviews, the Licensee/ Administrator did not ensure that the call system was in good repair at all times. This poses a potential hazard to residents in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 9
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
08/13/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240813110806

FACILITY NAME:HILLTOP SPRINGS SENIOR LIVINGFACILITY NUMBER:
455002932
ADMINISTRATOR:O'FARRELL, KEILAFACILITY TYPE:
740
ADDRESS:7 HILLTOP DRTELEPHONE:
(530) 395-1777
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:211CENSUS: 172DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:KEILA O'FARRELLTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Neglect/Lack of Supervision
Staff mismanaged resident medication.
INVESTIGATION FINDINGS:
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On 03/04/25 Donna Gurriere and Kayla Adkison, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/13/24. LPA Gurriere met with Keila O’Farrell, Administrator and explained the purpose of the visit.

Neglect/Lack of Supervision

During the interview process, numerous staff working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Fall Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers.

continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 59-AS-20240813110806
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: 03/04/2025
NARRATIVE
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During the investigation process, it was reported that staff were present when the resident (Resident 1) fell in the common area while trying to ambulate around a chair. The resident tried to walk around a chair; however, her foot caught one of the chair’s legs and the resident fell onto her right hip. Three staff persons witnessed the fall and there was nothing that they could have done to prevent the resident from falling. The resident was sent to the hospital shortly after the fall; she suffered a hip fracture.

Unsubstantiated.

Staff mismanaged resident medication.

During the interview process, the administrator and seven staff persons working in the memory care unit were interviewed. Residents were not interviewed based on their dementia status. In addition, records were obtained to include the resident’s (Resident 1) Physician Report, Admission Agreement, Communication document, Medication Administration Records (MARs), Hospice Notes, Initial Plan of Care, Pull Switch Log, Service Plan, Fall Preventions/Safety Measures for Falls, Incident Reports of Fall Injuries, and Staff Names and Cell Phone Numbers.

During the investigation process, it was reported that the resident (Resident 1) had moved, and the resident did not have medications available to review. The resident’s MARs were reviewed and were in order, as required.

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 the above findings are Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9