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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002932
Report Date: 12/17/2025
Date Signed: 12/17/2025 02:08:17 PM

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
08/18/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250818122437
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: 110DATE:
12/17/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Tracy LehnerTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staff to meet resident needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
12/17/2025 at 01:30 PM Licensing Program Analysts (LPA) Sarah Benson made an unannounced visit to the facility and met with Administrator Tracy Lehner. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA conducted interviews and reviewed the following documents: Resident rooster, staff list and phone number, staff schedule a report of concierge incident reports.



Continued on 9099C & 9099D

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

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
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 3
Control Number 59-AS-20250818122437
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: 12/17/2025
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
Insufficient staff to meet resident needs.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

During the investigation process, most of the people interviewed reported there has been a history of about once a month when there is only one medication technician to cover assisted living and memory care. It was reported on occasion there is one person to care for all the residents of memory care. It was reported that when a resident falls, the medication technician is called to assist, which is difficult when covering both floors, five medication carts with all of the residents’ medications.

It was determined there has been lack of staffing at times. Based on (title 22) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is 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 exit interview 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: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20250818122437
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: 12/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/17/2026
Section Cited
CCR
87413(a)(1)
1
2
3
4
5
6
7
87413 Personnel - Operations
(a) In each facility:
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.
1
2
3
4
5
6
7
Administrator will provide two qualified medication technicians for each shift.
Administrator will email a copy of the medication technician schedule.
Administrator will notify LPA of sick calls during this time.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on interviews and review of records, the licensee/administrator did not meet the resident’s needs, due to a lack of staffing. This poses an immediate risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3