Hilltop Haven 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. LPA Urena spoke with the Administrator and inform them of the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher/s were fully charged and were last purchased on 12/05/2025. The LPA observed required postings by the main door foyer. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The washer and dryer room is adjacent to the kitchen. The laundry supplies are locked in a top cabinet. BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. BATHROOMS: Bathroom/s were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. Continues on LIC 809C... OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. The passageways are clear of obstructions. No bodies of water were noted. RECORDS: Records review began at 11:30 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began 12:05 pm; medications are centrally stored and locked in a locked closet by the front foyer; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 13, 2025

Allegation investigated: Staff are not following physician's orders. Residents are left in soiled diapers for an extended amount of time.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegations listed above and to deliver findings. The LPA met with Administrator Thomas Stiles and Cathy Harris and explained the reason for the visit. On 11/14/2024, LPA Urena conducted an initial visit to investigate the allegations listed above. The LPA interviewed the facility representative, staff, residents, and residents’ representatives from 11:01 a.m. to 1:45 p.m., and requested records pertinent to the investigation. Continues on LIC 9099C... Unsubstantiated Staff are not following physician's orders. On the allegation that staff are not following doctor’s orders, it is the concern of the Reporting Pary (RP) that the staff are not repositioning residents every two hours as indicated by the resident’s (R1) physician’s orders. To investigate the allegation, the LPA interviewed staff, residents, and the RP. Per the RP, the resident’s representative visited the resident during the weekend; after four (4) hours of being at the facility, R1’s representative noticed that the staff (S1) failed to turn the resident (R1) every two hours per doctor’s orders. When the resident’s representative asked the staff on site (S1) to reposition R1, the staff stated that they could not do it (physically). Furthermore, the R1’s representative stated that S1 was the only one at the facility on the day of the visit. The LPA interviewed the residents, and two (2) out of three (3) residents stated that they do not need assistance with repositioning, one resident stated that they get assistance from staff to turn and reposition throughout the day. Residents stated that typically, the facility’s representative is at the facility on weekends along with S1. The interview with the facility’s representative revealed that they were at the facility on the day of the visit, however they admitted that they went out to do some shopping for groceries and were not gone for more than an hour. The LPA was unable to interview S1, or R1. Record review revealed that R1 resided at the facility for two weeks, was admitted to the facility with hospice services; hospice record review indicated that R1 had to be reposition every two hours. Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed Unsubstantiated at this time. Residents are left in soiled diapers for an extended amount of time. On the allegation that residents are left in soiled diapers for an extended amount of time, it is the concern of the reporting party that residents get a diaper change only twice a day, once in the morning and once at night. To investigate the allegation the LPA interviewed staff and residents. The staff interviews revealed that staff check on residents every two hours day and night, but may need to change soiled diapers more often, depending on the need of the residents. Furthermore, staff stated that residents have a call button to call staff if they need to have a diaper change. The residents’ interviews revealed that they get a diaper change more often than two times a day, and/or as needed. Based on the information obtained through residents’ and staff interviews, it is apparent that residents get a diaper change throughout the day, and as needed or requested by residents. Therefore, the allegation is deemed Unsubstantiated at this time. No citations were issued at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 14, 2025 · control 29-AS-20241112154102

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. LPA Urena spoke with the Administrator and inform them of the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher/s were fully charged and were last serviced on 12/30/2024. The LPA observed required postings by the main door foyer. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 116.5 degrees Fahrenheit. The washer and dryer room is adjacent to the kitchen. The laundry supplies are locked in a top cabinet. BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. BATHROOMS: Bathroom/s were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured at 116.2 degrees Fahrenheit. Continues on LIC 809C... OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. The passageways are clear of obstructions. No bodies of water were noted. RECORDS: Records review began at 11:30 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began 12:05 pm; medications are centrally stored and locked in a locked closet by the front foyer; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 31, 2024

Allegation investigated: Staff pressured a resident with declining health and competency to make a financial deal for their personal gain.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver the findings for the allegation listed above. The LPA arrived at the facility and met with the Administrator Cathy Harris. The LPA informed them of the reason for the visit. On 09/11/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day unannounced visit to investigate the allegation listed above. The LPA arrived at the facility and met with the Licensee Tom Stiles. The LPA informed them of the reason for the visit. At 11:45 a.m., the LPA interviewed the Licensee and requested records pertinent to the investigation. The LPA interviewed the Reporting Party (RP) on 09/09/2024 at approximately 10:48 a.m., acquaintances on 09/11/2024 from approximately 10:35 a.m. to 11:28 a.m., POA on 09/17/2024 at approximately 11:15 a.m. Continues on LIC 9099C... Unsubstantiated Staff pressured a resident with declining health and competency to make a financial deal for their personal gain. On the allegation that Staff pressured a resident with declining health and competency to make a financial deal for their personal gain, the reporting party’s (RP) concern is that the facility staff conducted themselves in an unethical manner by trying to coerce resident (R1) into a financial agreement with the facility staff. The RP stated that there was nothing in writing to document the coercion of the financial deal, that the coercion was done verbally. The LPA could not interview (R1), since R1 is no longer residing at the facility. To investigate the allegation, LPA Urena interviewed the Reporting Party (RP) on 09/09/2024. The RP’s interview revealed that on at least two different occasions (May 2023 and summer of 2023), staff made unethical financial proposals to R1, while R1 was residing at the facility. R1 told the RP that the Administrator offered R1 to live for the rest of their life at the facility, if R1 made a financial investment with the facility staff and gave all of their financial assets to the facility staff. At the time of the financial proposals (2023), the RP stated that R1 was declining in health, and could not make competent decisions. The RP’s report stated that R1 is now suffering from the effects of Parkinson's disease, is highly suggestible and has no reasoning skills. R1 hallucinates and rambles nonsense now. The LPA interviewed the Administrator, and they denied attempting to make financial deals with (R1) or pressuring them to make a financial deal for their personal gain. The Administrator stated that they often took R1 on outings (medical appointments, and lunch). On the day they went out to see properties, the administrator stated that they and another staff were talking about seeing some properties, and that R1 overheard them, and asked if R1 could go with them, and the administrator said, “yes”. However, the administrator denied making any financial offers to R1. On 09/14/2024, the LPA interviewed the Power of Attorney (medical POA) for R1. The POA stated that they were not aware of any coercion or financial deals being offered to R1. The POA stated that they spoke almost every day with R1, and R1 would have said something to them had such offer had been made by the staff. Furthermore, the POA stated that R1 liked being at the facility and liked the licensee and staff very much. POA stated that R1 was transferred to another facility to be closer to the POA. Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove that Staff pressured the resident to make a financial deal for their personal gain. Therefore, the allegation is deemed Unsubstantiated at this time. Interview exit was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 29-AS-20240905191311

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 10am. Upon arrival LPA met with Staff and explained the reason for the visit. Shortly after Administrator Edward Duffels and Caregiver Tom Stiles arrived. At approximately 09:00am, tour of the physical plant was conducted with Stiles and Duffels. Facility has (4) resident bedrooms and a staff room. (2) of the bedrooms are private resident rooms. Hallway bathroom is designated for common use. All resident rooms have a private bathroom, with the exception of resident room 4. LPA toured the facility with Stiles. The kitchen appeared to be relatively clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer in the office area on the left side of the kitchen. LPA observed drawer to be locked at this time. Laundry area was located next to the kitchen. Cleaning products were observed to be inaccessible to residents in care at this time. The fire extinguishers were fully charged and last purchased on 11/17/2023. There is a dedicated area for the posting of required documents located in the office area in the kitchen. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture appeared to be relatively clean and functional at this time. At 9:30am, LPA observed (2) residents eating breakfast. Continued from 809 The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed (5) bedrooms that includes a staff room. Staff room was observed to be inaccessible to clients in care and empty at the of the visit. Extra linen is kept in a cabinet in the hallway. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet nearest to common bathroom. All bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured between 105 and 120 degrees Fahrenheit. There is enough clean linen available in stock at the linen cabinet. Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There is an above ground drained spa enclosed and locked inaccessible to residents in care. LPA observed a sufficient amount of space for activities. LPA did not observe any obstructions to emergency exit at this time. The backyard and exterior area of the facility is completely fenced with a self-latching gate at the facility entrance. At approx. 09:45am, LPA observed at the rear of the facility is a detached garage and an Adult Dwelling Unit with three (3) units, where caregivers Tom and Cathy reside. The landlord resides in the middle unit. Each unit was observed to be empty at the time of the visit. This area is separated by a fence. The detached garage was observed to be inaccessible to residents at this time. In the garage, LPA observed a boat, furniture and multiple household items. Records review began at approx. 09:45am, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. three (3) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be in order at this time. Medications review began at approximately 11 a.m. The medications are centrally stored in the medication cabinet closet near the laundry. Medications are properly documented on the centrally stored medications and destruction record. Continued from 809-C Between 1pm - 2pm , LPA interviewed three (3) residents and three (3) staff. The LPA spoke with Tom regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate room #4 as a single isolation room if the facility has a confirmed case of a communicable disease. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time. During the visit, LPA obtained an updated Limited Liability insurance, Census and LIC 500 Exit interview conducted and a copy of the report issued. Continued from 809-C Between 1pm - 2pm , LPA interviewed three (3) residents and three (3) staff. The LPA spoke with Tom regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate room #4 as a single isolation room if the facility has a confirmed case of a communicable disease. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time. During the physical plant LPA observed the physical plant was not consistent with the submitted facility sketch/floor plan when this facility was initially licensed, as the sketch indicates there are (2) separate buildings in the rear of the lot, when there is actually (1) L shaped building split into three (3) units for two (2) of the caregivers and the landlord. An updated STD 850 will be provided to the Department. During the visit, LPA obtained an updated Limited Liability insurance, Census and LIC 500 Exit interview conducted and a copy of the report issued.the state’s words, verbatim · CDSS document, Dec 7, 2023