Hillcrest Senior Living

Allegation investigated: staff did not ensure adequate supervision was provided to resident in care resulting in resident’s death Staff did not ensure medication records were properly managed

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Mary Alvarado and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated November 17, 2025, R1’s Hospice records dated December 1 through 28, 2025, R1’s Death Certificate, Facility Death report dated December 28, 2025, R1’s Appraisal/Needs and Services Plan dated November 17, 2025, and R1’s Admission Agreement dated November 22, 2025. The investigation into the allegation, staff did not ensure adequate supervision was provided to resident in care resulting in resident’s death, revealed the following. Unsubstantiated It was reported that facility staff administered medications to R1 on December 24, 2025, and that staff caused R1 to vomit on December 25, 2025, which led to the death of R1. It was reported that R1 began to decline because of these actions which eventually led to R1’s death on December 28, 2025. R1 moved into the facility on November 22, 2025. According to R1’s physician’s report dated November 17, 2025, R1 was diagnosed with Alzheimer’s Disease late onset. R1 moved into the facility under Hospice care. R1 was provided with Hospice care almost daily. A review of medication records shows R1 received their routine medications for December 1 through 24, 2025, except for Triamcinolone Acetonide ointment 0.1%. Staff 1 and Staff 2 reported that after December 24 R1 could not take medication. Hospice Nurse 1 and Hospice Nurse 2 reported that they only administered liquid morphine to R1 after December 24, 2025, as R1 could no longer take medication except in liquid form. A review of records shows On December 25, 2025, Staff 1 (S1) reported that R1 was unresponsive and had vomited. S1 did not recall what time the incident took place. S1 reported that they cleaned R1 and called hospice. S1 did not recall how they cleaned R1’s mouth and why R1 had vomited. LPA interviewed Hospice Nurse 1 who cared for R1 on December 25 and December 28, 2025. Hospice Nurse 1 reported that R1 was having difficulty breathing and they administered oxygen. A review of hospice records for December 25, 2025, verified this information. No other issues were noted for R1 during the Hospice visit on December 25, 2025. No other incidents or issues were noted for R1 until December 28, 2025. On December 28, 2025, S1 reported that R1 was unresponsive and had labored breathing so Hospice was called. S1 reported they did not remember what time they called hospice. Hospice Nurse 1 responded to the call and assessed R1. Due to R1’s condition S1 requested that R1 receive continuous hospice care. Hospice Nurse 1 agreed and continuous Hospice care was approved for R1. Hospice Nurse 1 reported they do not remember what time they arrived at the facility. LPA interviewed Hospice Nurse 3 who completes the Hospice record notes. Hospice Nurse 3 reported that the only exact time on the hospice notes is the time of death because that is recorded and communicated immediately. The Hospice notes recorded are not exact times and are the times entered when the notes are completed not when the nurse arrives or when the facility calls. Hospice Nurse 3 reported that they complete the notes and don’t provide care to residents and don’t do facility visits, so the time on the daily notes are not necessarily accurate. Hospice Nurse 1 reported that they continued to provide care to R1 until they were relieved at 4:00 pm by Hospice Nurse 2. Hospice Nurse 2 reported they did not recall December 28, 2025, as they made numerous visits that day for people who were actively passing. Hospice Nurse 2 reported that their job is to make the residents as comfortable as possible and to help with a peaceful transition. Hospice Nurse 2 reported that if they ever suspected facility staff from neglecting or causing or contributing to someone’s death, they would report it. R1’s responsible party reported that they were called on December 25, 2025, about R1’s condition and on December 28, 2025, they were called so they went to visit R1. R1’s responsible party reported they were present when R1 passed away and didn’t recall specific details about the care that was provided to R1 on that day. R1’s responsible party reported that they never witnessed any actions by staff that were abusive or that could have led to R1’s death. Hospice Nurse 2 reported they don’t remember any issues with R1 or the facility that would be a cause for concern. Hospice Nurse 1 reported that they never witnessed any issues or had a cause of concern for R1 or the facility. Hospice Nurse 1 reported that they don’t believe anything the staff did contributed to the death of R1. Staff 2 (S2) was present at the facility when R1 passed away but reported they were caring for the other residents and weren’t involved with R1’s care that day. S1 reported that after Hospice arrived, they handled all of R1’s care needs. Hospice Nurse 1 verified this information. R1’s death certificate lists R1’s cause of death as Alzheimer’s Disease with Late Onset, on December 28, 2025, at 5:20 pm. No other contributing factors are listed. Hospice records for R1 dated December 18, 2025, state, “Over the past 15 days, the patient has exhibited a continuous and progressive decline in condition, consistent with the terminal trajectory of their end-stage disease.” None of the evidence gathered supports the allegation. Based on the evidence gathered through interviews and documents reviewed the allegation is deemed unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not ensure medication records were properly managed, revealed the following. It was reported that R1’s medication records were not properly recorded and documented. R1’s physician ordered R1’s medications to be crushed because of R1’s difficulty with swallowing. A review of records show R1 had routine medications and PRN medications (as needed) and a Hospice comfort kit of medications administered by Hospice Nurses stored at the facility including Morphine 20ml solution. A review of Hospice records show R1 was prescribed a total of 24 medications. Facility records show R1 was prescribed a total of 24 medications. Staff 1 and Staff 2 reported that R1’s medication records were current and reflected all of the medications they were prescribed. At the time of the initial 10-day visit (December 31, 2025) R1's medications were no longer at the facility and had been returned to the pharmacy, so R1's medications could not be inventoried. LPA reviewed R1’s medication records and they were kept in accordance with Title 22 California Code of Regulation (CCR) 87465. All medications administered by Hospice are listed on their visit reports and a copy was kept with R1’s records. No discrepancies were observed with the listing of R1's prescribed medications. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Administrator, and a copy of the report was provided. R1 was prescribed Triamcinolone Acetonide Ointment 0.1 % topical, for a wound that was discovered on their back around December 12, 2025. The medication was prescribed on December 15, 2025. The wound was not staged/classified and R1 was noted to be stable with no issues. The order for the medication instructed the ointment to be applied twice a day until resolved. A review of R1’s medication records shows that R1 was administered all their other routine medications but the entries for Triamcinolone Acetonide Ointment 0.1 % topical for December 1 through December 28, 2025, are all blank showing there is no record of it being administered. Staff 1 and Staff 2 could not explain why the medication administration record for Triamcinolone Acetonide Ointment 0.1 % topical was blank. Staff 1 and Staff 2 could not recall if Triamcinolone Acetonide Ointment 0.1 % topical was administered to R1. There is no evidence that R1 received their prescribed Triamcinolone Acetonide Ointment 0.1 % topical. Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 22-AS-20251231083634

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jul 31, 2026

To receive or reject medical care or other services. This requirement was not met as evidenced by, R1 did not receive their prescribed routine medication, Triamcinolone Acetonide Ointment 0.1 % topical, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee agrees to train staff on CCR 87468.1 and sign a statement of understanding for CCR 87468.1. Proof of correction to be submitted to the LPA by the POC due date.

Type of visit: Collateral

On May 7, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of conducting a collateral to interview and obtain records for Resident #1 (R1) in connection to an investigation at another licensed facility for complaint control number: 22-AS-20260430132811. LPA was greeted and granted entry by Caregiver Blanca Gonzalez who then advised Administrator's Assistant Mark Realis by telephone the reason for the visit. During today's visit, LPA interviewed R1 by telephone and obtained the following records: Photo Identification, Identification and Emergency Information, and page 1 of the Admission Agreement. An exit interview was conducted with Caregiver Blanca Gonzalez authorized by Assistant Administrator Mark Realis, and a copy of this report was provided via email at exit.the state’s words, verbatim · CDSS document, May 7, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Blanca Gonzalez after introducing and stating the reason for the visit. LPA also met with Administrator Mary Jean Alvarado and Administrator's Assistant Jilmark Realis. Admin Alvarado has a valid certificate expiring on 6/8/26. The following was observed during the inspection: This is a single story property comprised of four resident bedrooms and four resident bathrooms. There is an additional private bedroom designated for two live-in staff. Facility is operating within the conditions and limitations specified on the license. LPA observed five residents in care, one of which is receiving hospice service. LPA toured the interior portion of the facility. The facility is clean and in good repair. All common areas were inspected including the attached two car garage. LPA inspected all resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found be in compliance, clean, and operational. Slip resistant mats were available. The hot water temperature in the resident bathrooms did not meet the regulation measuring at 117.8, 118.4, 121.1, and 120.9 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gate is operational, and there were sufficient seating and shading in the patio area. There are no bodies of water on premise. The fireplace in a resident's bedroom was screened. The fire extinguisher was mounted, charged, and serviced on May 9, 2024 which did not meet the regulation. The auditory devices and smoke/carbon monoxide detectors were tested and operational. However, the smoke detector that was removed in one resident's room had to be reinstalled and Admin will ensure that it is operational. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. LPA reviewed two personnel files in which no discrepancies were found. Staff training is completed for one of two staff. Staff #2 (S2) has a start date of April 15, 2026, and Admin stated S2 will receive training immediately. LPA reviewed five resident files in which discrepancies were found as no Medical Assessments (LIC602s) which include Tuberculosis (TB) tests were not completed for two of five residents. Medications were audited for two of five residents. However, medications administered were not documented on the Medication Administration Record (MAR) for both residents timely missing 3-13 days. Present staff is background cleared and associated to the facility. Disaster drills are conducted quarterly as last known drill per log was conducted January 20, 2026. LPA consulted on the following: to ensure that the resident/personnel files are maintained and organized to prevent future delays in visit, to ensure medical assessments are completed and TB tests are obtained timely, to ensure the hot water temperature is within a comfortable range of 105-120 degrees Fahrenheit, to ensure fire extinguisher is serviced or purchased annually, to ensure resident does not remove the smoke detector and to ensure it's operational, and to ensure staff completes the Medication Administration Record timely. Based on the observations made during today's visit, deficiencies are being cited, and Technical Violations are also being issued. An exit interview was conducted with Administrator Mary Jean Alvarado and Administrator's Assistant Jilmark Realis, and a copy of this report including the appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Apr 24, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Blanca Gonzalez. Administrator (AD) Mary Jean Alvarado was notified via telephone by staff. For today’s visit, LPA observed a total of two residents in care and two staff member on duty. LPA observed the AD certificate for AD Mary Jean Alvarado which expires on June, 08, 2026. LPA Ramirez toured the interior and exterior portions of the facility with Caregiver Eisenhower Belo. The facility is a single level structure and is licensed for five non-ambulatory, one bedridden and has a Hospice waiver for four. For this visit, there are a total of five residents in care. There are a total of six bedrooms, of which five are private resident bedrooms. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector were tested and operational. There are a total of four restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 105.4-105.6 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located by the dining room. Fire extinguisher was service on May 09, 2024. CONTINUED ON LIC809-C... LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the dining room. Facility had back-up emergency food and water supply. LPA observed that the First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. Medications are locked in a cabinet in the garage. For the exterior portion, LPA Ramirez observed a shaded area with patio furniture, and the grounds were free of any hazards. There is one gate in the backyard. No bodies of water were observed. LPA reviewed two resident files and three staff files. LPA interviewed residents and staff present. For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative. A copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Mar 19, 2025