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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002932
Report Date: 02/27/2026
Date Signed: 02/27/2026 12:49:35 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
12/05/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20251205083001
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: 101DATE:
02/27/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Tracy LehnerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not properly supervising a resident who is a fall risk.
Staff took away resident's personal belongings.
INVESTIGATION FINDINGS:
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On February 27 2026, Sarah Benson, Licensing Program Analyst (LPA), arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 12-05-25. LPA Benson met with Tracy Lehner Administrator, Howard Hartman Medication room manager, Lorena Kot Health Service Manger, Administrator, and explained the purpose of the visit.

During the interview process, five staff persons were interviewed. The following documents were received and reviewed: staff list and phone number, staff schedule, admission agreement, care plan, call button records and a photo.


Continued on LIC9099c & LIC9099D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026
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-20251205083001
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: 02/27/2026
NARRATIVE
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Staff are not properly supervising a resident who is a fall risk.
During staff interviews, S2 stated it is very rare that we have only one care staff. S2 stated maybe once a month, but not usually. S4 stated the staff are not checking on the residents every couple hours. S4 stated the management put fifteen residents to one care staff. S4 stated when I have two fall risk one in the front and one in the back, which one do I go to first. Staff reported a resident fell when I was working by myself, a resident fell when I was at the other end of the building and didn't hear the alarm. Staff reported this caused the resident to be left on the floor for an extended period of time. Staff stated we have pull alarms attached to residents that are a fall risk, It sounds a loud alarm. Staff stated the pendent report goes to all staff with a tablet.
S3 stated the medication technicians are busy with the medication and don’t have time to help the care staff. S3 stated we were working double shifts. S3 stated the alarms the residents wear on their person didn’t work, the tablet batteries were dead half of the time.
During the investigation S2 and LPA went to R2s room to check the sound of the call button. Staff turned on the alarm while LPA went to the opposite end of the facility, LPA could not hear the alarm. It was reported the call button usually bought was unavailable and the new call button alarm was not as loud. S2 found an old facility call button, LPA and S2 tested the alarm and it could be heard at the opposite end of the facility.

Staff took away resident's personal belongings. During staff interviews the Administrator reported an individual called and ask staff to take R1’s phone as they were calling them too often. The Administrator informed the individual they could not take R1s phone as it violated the residents’ personal rights. Staff stated the individual called back and ask another staff to take R1’s phone because R1 was calling too often and the staff took the phone and placed the phone in the staff work area. Staff stated this happened months ago. Staff stated It may have been a few hours that we had possession of the phone before it was returned to the resident.

Based on investigation observations and interviews which were conducted and record review(s), 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.

An exit interview was conducted and appeal Rights provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20251205083001
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: 02/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2026
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The alarm system has been replaced.
The plan of correction has been completed.

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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 the requirement accorded safe, equipment. The alarm was not loud enough. This poses an immediate health and salety risk to residents in care.

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Type B
03/27/2026
Section Cited
HSC
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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The administrator will have a training concerning personal belonging and personal rights.
The administrator will notify LPA when completed.
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This requirement was not met as evidenced by: interviews, the licensee/administrator did not meet the resident’s needs, due to staff took the residents phone. This may pose an immediate health and safety risk 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: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3