Hilltop Springs Senior Living

Type of visit: Case Management - Incident

On 08/26/2026, licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to follow up on a incident report that was submitted to licensing on 08/24/2026. LPA Chiarelli met with Business Officer Manager Carmela Crandall and explained the purpose of the visit. LPA Chiarelli interviewed three staff members and interviewed one resident (R1). Several topics were discussed and copy of report left with the facility.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Case Management - Deficiencies

On 08/13/2026 licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to follow up on findings from an annual inspection that was completed on 08/07/2026. LPA Chiarelli met with administrator Tracy Lehner and explained the purpose of the visit. While conducting the annual inspection on 08/07/2026, LPA Chiarelli observed a camera with audio capabilities which was located in one of the resident's (R1) room in memory care unit. After further investigation and speaking with licensing program manager (LPM) Lauren Crocker, it was determined the camera was in violation of health and safety code (refer to 809-D) for further information. One deficiency is being cited on today's visit. Exit interview conducted and copy of report left with the facility.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Aug 27, 2026

1569.269(a)(5) Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. The licensee did not comply with the section cited above as evidenced by: Observation, interviews and record review. Facility placed a camera with audio capabilities into a R1 room, which poses a potential, safety, health or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee will remove the camera from R1 room. Licensee will conduct a training with all staff about resident's privacy and cameras use in the facility.

Type of visit: Required - 1 Year

On 08/07/2026, Licensing program analyst (LPA) Marisa Chiarelli arrived to the facility unannounced to conduct a one year required inspection. LPA Chiarelli met with Administrator Tracy Lehner and explained the purpose of the visit. LPA Chiarelli and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured included but not limited to, residents bedrooms, bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medication is kept in a locked room. LPA Chiarelli completed a medication review. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Sharps are kept in a locked drawer. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke and carbon monoxide detectors are all in working order. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. No firearms are on premises. One deficiency and one technical violation was cited on today's inspection, exit interview conducted and copy of report left with the administrator.the state’s words, verbatim · CDSS document, Aug 7, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents Staff do not ensure residents receive clean linens for their beds Staff do not ensure residents call buttons are answered promptly Staff do not ensure residents take their medications once dispensed Staff do not ensure residents rooms are kept clean Staff do not ensure residents receive bathing assistance Facility is charging for services not provided to residents in care

On July 29 2026 licening program analyst LPA Sarah Benson arrived at the facility unannounced to deliver complaint findings. LPA Benson met with Memory Care Director Waniesha Ortiz and explained the purpose of the visit. LPA Benson toured the facility and did staff interviews. During the investigation interviews were conducted, four staff persons and four residents were interviewed. The following documents were received and reviewed: staff list and phone number, staff schedule, admission agreement, care plan, call button records, cleaning records, laundry records, MAR and shower logs. Continued on LIC9099C Unsubstantiated The allegation: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents During resident interviews a resident stated I recommend them, they take care of everything. A resident stated that anytime I push my button things are fine. Another resident stated my care needs are met for sure During staff interviews, staff stated at least twice maybe more, when I went to shower the resident she had already been given a shower by her daughter. LPA record review revealed the residents care plan states the resident request help with bathing, requesting staff nearby in apartment for time-to-time assistance and safety issues. Record review of service plan states that staff will remove trash every shift, with weekly bed change and laundry cleaned on Thursday’s. LPAs’ observation during the inspection and interviews LPA Benson observed (4) four out of four residents’ trash emptied and clean rooms. Unsubstantiated. The allegation: Staff do not ensure residents receive clean linens for their beds During staff interviews, Staff reported once a week housekeepers change the linens on the bed, residents are asked to leave sheets out so staff won’t have to riffle through the residents’ belongings. Staff stated if bedding is soiled the care giver is responsible to change the bedding. Staff stated I am the follow up, if a family member or resident says my bed didn’t get changed then I will make sure it gets done. S2 stated we have a chart on the wall in the charting room on the first floor. Staff reported the charts often get messed up, when family or residents change laundry or shower days. S2 stated we pull the bedding when a shower is done and laundry is done on a separate day. S2 stated each resident has a service plan. S3 stated It is in the routine, to make sure the beds are clean. S3 stated If the resident only has one set of sheets, we ask the family to bring more. Staff stated it is our responsibility to make sure the linens are changed and there are serious consequences if we don’t do it. During resident interviews resident one R1 stated if I don’t pee on the bed then my little dog does. R1 stated my family comes and helps change the pee mats on the floor and takes my dog for walks. Resident three R3 stated they are not right on top of that, maybe two weeks will go by without changing my sheets. R3 stated they are supposed to do it automatically, I’m not sure what to do. During interviews the majority of residents reported the beding is changed weekly or sooner. Record review of service plan states that staff will remove trash every shift, with weekly bed change and laundry. Unsubstantiated. The allegation: Staff do not ensure residents rooms are kept clean and trash is not removed from their rooms promptly. During staff interviews, S1 stated the care staff will take out the garbage daily as needed. S1 stated we have talked about getting a covered garbage cans when depends are used. S2 stated I have witnessed a room not up to standard, when I have done a room check. S2 stated when this happens, I call care staff back to the room to clean it. S2 stated staff are required to take out the garbage per shift, it there is a smell or something soiled it is taken care of immediately. S3 stated when a resident has a pet it is the responsibility of the resident or family to take care of the pets needs. S3 stated some residents hire private care givers to take care of the pets. S3 stated I don’t usually see the wet pee pads on the floor. S4 stated the resident’s rooms always tend to be clean, we have house keepers and I do the dishes or clean up messes. S4 stated at times the garbage can be overflowing when I come in the morning shift, because the previous shift didn’t take them out. S4 stated some residents are independent with toileting and by the morning have a few depends in the garbage. During resident interviews R1 stated my room is kept clean, it’s fine. R2 stated I do my own dusting, staff clean the bathroom and kitchen, floors and they take out the garbage. R3 stated It’s ok, I have no complaints. R4 stated the room is cleaned once a week. R4 stated I have been on their case about taking out the garbage. R4 stated the staff changes the depends then leaves the dirty depends in the room to stink up the room. Record review of residents service plan states that staff will remove trash every shift, with weekly bed change and weekly laundry service every Thursday. LPAs’ observation during the inspection and interviews LPA Benson observed (4) four residents’ rooms that were tidy, clean and trash was emptied. Unsubstantiated. The allegation: residents are brought to the dining hall late even after pressing their call buttons, and staff take a long time to respond to call buttons. During staff interviews, S2 stated we try to get to the call lights as soon as we can. S2 stated if we are assisting a resident then we will reach out to other staff for assistance. S2 states we have one care staff on each floor. S2 stated and one med tech on floor one with one med tech covering floor two and three. S2 stated we have staff have a tablet, that shows who pushed the call button first. S2 stated we help in order of when the button was pushed. S2 stated staff get to know the residents that want to go to dinner early. S3 stated we currently try to get to residents quickly; we may be assisting a resident that takes a longer time. S4 stated it differs every day as to who I work with. During resident interviews Resident one R1 stated I don't have a problem with that, I don’t push my button. R2 stated anytime I push my button things are fine. R2 stated staff show up, it isn’t within minutes, but it is fine, During file review LPA Benson received a copy of the third-floor pendant alarm call request/response record. LPA observed the said resident did not push their pendant from April 28 to May 22 2026. LPA’s record review revealed the majority of calls of neighbors were answered in less than eight minutes with the longest response time as twenty four minutes. Unsubstantiated. The allegation: Staff do not ensure residents take their medications once dispensed. During staff interviews, Staff stated I do not let residents take their medication with them, I must watch the residents take the medication. Staff stated I tell the resident that I can take the medication to them if they want to take their medication a little later. Staff stated I believe it is in our training videos that the resident needs to take the medication when given. It was reported some of our residents take care of their own medication. Staff reported it is not protocol to let a resident wait to take their medication after we administer it. Staff stated I have not found any misplaced medication. During resident interviews R1 stated, I didn’t find a pill. R2 stated staff take care of my medication. Resident reported, staff always stay right here and make sure I take my medication. Resident four R4 stated I have observed staff don’t leave until my partner takes their medication. Unsubstantiated. The allegation: Staff do not ensure residents receive bathing assistance During staff interviews, S2 stated staff are required to ask about getting a shower, if they refuse we get a change of face, three times. S3 stated it is ADL routine; we have protocol for shower refusals. S3 states the clients have the right to have family assist. S4 stated our shower log can be messed up as the residents will switch their shower days and or refuses the shower. S4 stated the residents family often gives the resident her shower. During resident interviews Resident one R1 stated I don’t get my shower here, my daughter has a beautiful house they take me there for that. During LPA record review LPA observed a shower log with the resident scheduled for shower assist on Tuesdays and Fridays. LPA record review of resident shower logs for three months revealed twice on 4-24-26 and 5-8-26 a note stating, “not shower day”. Staff stated at least twice maybe more, when I went to shower the resident she had already had been given a shower by her daughter. Unsubstantiated. The allegation: family provide services they are paying the facility to perform, including shower assistance, changing bedding and laundry. During staff interviews, S1 stated laundry is provided, one load of laundry and one load of towels weekly. S1 stated housekeeping, laundry and rides are part of the rent. S2 stated the service chart stating the laundry schedule is in the charting room on the first floor. S2 stated we will change bedding and wash as often as needed. Staff stated R1 may need a higher level of care. The administrator stated all assisted living residents receive weekly housekeeping services including weekly laundry ,bed change and rides as part of the rental agreement with no extra charge. The administrator stated it is the responsibility of the residents to put the clean bedding out so staff won’t have to look through the residents belonging for the clean bedding. caregivers are responsible for that and are supposed to go to the resident’s rooms to do checks at least once a day. LPA observed four out of four residents’ rooms to be clean and orderly, the garbage was taken out. LPAs record review revealed resident receives weekly housekeeping, trash, vacuum, tidy, dusting and bed making. The residents care plan states weekly housekeeping along with weekly bed change, all trash removed every shift. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 59-AS-20260518082320

Type of visit: Case Management - Other

On July 9 2026 Licensing Program Analyst LPA Sarah Benson arrived at the facility to conduct interviews concerning complaint 20260518082320 received May 8 2026. LPA and staff Administrator Tracy Lehner toured the facility, LPA performed interviews with staff and residents to ensure the health and safety of residents in care. LPA requested the following documents, staff cleaning list and shower logs in the charting room. No deficiencies were cited during this visit. Department will follow up further if warranted. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Other

On May 28 2026 Licensing Program Analyst LPA Sarah Benson arrived at the facility to conduct interviews concerning complaint 20260518082320 received May 8 2026. LPA and staff Administrator Tracy Lehner toured the facility, performed interviews with staff and residents to ensure the health and safety of residents in care. LPA requested the following documents, laundry schedules, call button response, cleaning schedule, shower logs and client service plan. No deficiencies were cited during this visit. Department will follow up further if warranted. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Staff refused to administer medication to resident.

On 05/13/2026, Licensing program analyst Marisa Chiarelli arrived at the facility to deliver final complaint findings for complaint received on 12/19/2025. LPA Chiarelli met with Carmela Crandall and explained the purpose of the visit. Allegation - Staff refused to administer medication to resident. During the course of the investigation, LPA reviewed facility records, resident records, Resident could not be interviewed. Continued on 9099-C Unsubstantiated Complaint alleges that staff refused to administer medication to resident. During the investigation LPA could not prove or disprove the above allegation. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Exit interview conducted, and copy of report was left at the facility.the state’s words, verbatim · CDSS document, May 13, 2026 · control 59-AS-20251219102511

Allegation investigated: Staff left residents room soiled with feces.

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 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 Unsubstantiated Staff left residents’ room soiled with feces. On 12-09-25 Licensing Program Analyst LPA Sarah Benson inspected the room with the Administrator. During the inspection the room and floor were clean and free of odor. At the time of the inspection the Administrator shared a picture of a spot about 1 inch by 2 inches on a carpet. The Administrator stated on 12-07-25 It was reported to me by a staff member of a spot on the floor of a resident’s room that had been there for months. Administrator stated, I went to the room and there was a soiled spot on the floor about one inch by two inches. The Administrator shared a photo of the spot with LPA Benson. Administrator asked staff why it was not reported. Administrator stated the staff member stated they had given a handwritten note to another staff and it was reported to corporate five times, “I don’t know who”. Administrator stated it was never reported to me, the staff member didn’t report it to the proper staff through the proper channels. Administrator stated that housekeeping cleaned the floors on 12-07-25, the same day the spot was brought to my attention. During the investigation it was reported that a residents room was soiled with feces for months. During the investigation the LPA inspected the room and found it clean and odor-free. The Administrator shared a picture of a spot that was not identified, 1 inch by 2 inches. It was reported that the spot was cleaned when brought to the Administrators attention. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. An exit interview was conducted and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 59-AS-20251205083001

Allegation investigated: Staff are not properly supervising a resident who is a fall risk. Staff took away resident's personal belongings.

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 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.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 59-AS-20251205083001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 27, 2026

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. 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.the state’s words, verbatim · CDSS document, Feb 27, 2026

Plan of correction: The alarm system has been replaced. The plan of correction has been completed.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(3) · Plan of correction due date: Mar 27, 2026

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. 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.the state’s words, verbatim · CDSS document, Feb 27, 2026

Plan of correction: The administrator will have a training concerning personal belonging and personal rights. The administrator will notify LPA when completed.

Allegation investigated: Insufficient staff to meet resident needs.

/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 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.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 59-AS-20250818122437

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(1) · Plan of correction due date: Jan 17, 2026

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. 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.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: 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.

Allegation investigated: Personal rights.

/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. Unsubstantiated. Continued on 9099C Unsubstantiated Personal rights. Homeless people enter the facility multiple times and harass staff. It was reported the facility has no nighttime security. During the interview process the Administrator stated we have a security team from 10:00pm to 6am. Staff stated the night concierge acts as our security. Staff reported that one of the security teams responsibilities is to let EMS in and direct them to the residents in need of assistance. Staff stated all off the doors lock around the perimeter, a key fob is needed to get in. Staff stated the front door is locked from 7am to 7pm. It was reported one evening someone was trying to get in the building without a key fob, but did not get access. Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, the findings are Unsubstantiated. A copy of the report was provided to the facility representative listed above and exit interview conducted.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 59-AS-20250818122437

Allegation investigated: Staff forced resident to have blood drawn.

On 12-11-25 Licensing Program Analyst (LPAs) Sarah Benson and Marisa Chiarelli, arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08-07-25. LPAs Benson and Charelli, met with Administrator Tracy Lehner, and explained the purpose of the visit. During the interview process, three staff persons and one residents were interviewed. Documents were received and reviewed to include the resident rooster, staff list and phone number, staff schedule, resident admission agreement, physician report and medical records. Continued on 9099C Unsubstantiated Staff forced resident to have blood drawn. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. During interviews, Staff stated I have never forced a resident to have their blood drawn. Staff stated If a resident doesn’t want their blood drawn, we don’t make them. Staff stated I didn’t know that R1 didn’t want labs drawn. During LPA Bensons visit, staff verified with the lab and the resident did have her blood drawn. During resident interviews the resident R1 stated on 7-2-25 very early in the morning the medication technician opened the door and let in the lab staff. R1 reported the med. tech stated that the lab was here to draw my blood. R1 stated I told the medication technician I didn’t want my blood drawn. R1 stated the med. tech. told the lab staff to take my blood. R1 stated it was early, I was still drowsy and I ask who authorized this blood draw, they said they didn’t know. R1 stated I was so sleepy I didn’t tell them no, I was still in my pj’s. The resident stated I didn’t tell them no and therefore the allegation is unsubstantiated. Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, the findings are Unsubstantiated. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report was given to Administrator.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 59-AS-20250807124303

Type of visit: Case Management - Incident

On 12-9-25 Licensing Program Analyst LPA Sarah Benson arrived at the facility to conduct a case management visit. LPA met with Memory Care director Waniesha Ortiz and explained the reason for the visit. The department is following up on an Incident Report (IR) submitted by the facility on 11-15-25 concerning a fall with an injury. It was reported on 11-15-25 resident R1 had fall with injury. Care staff was conducting rounds when they found R1 on the floor between her bed and dresser. Staff conducted a full body check. R1 complained of pain in her head, back, and hips. R1 had a bump on the back of head and skin tear on right forearm. R1 stated she fell out of bed. EMS arrived and transported R1 to Hospital. LPA Benson conducted interviews. At this time, this case is under review and the department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Case Management - Incident

On 11-3-25 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Tracy Lehner, Memory Care director Waniesha Ortiz and explained the reason for the visit. The department is following up on a Death Report/Incident Report (IR) submitted by the facility on 10-29-25. LPA requested the following documents: discharge paper work, emergency room visit, MAR, admission agreement, care plan, progress notes and alert charting records. Staff reported the resident moved to memory care 10-20-25. Staff reported on 10-22-25 a family member took the resident to have teeth removed/oral surgery. Family brought the resident back to the facility after the surgery. Staff reported on 10-28-25 the resident had a fall at 3:00am and was sent out to the hospital. Staff reported the resident was returned to the facility about 10am on 10-28-25 with a fracture to left arm by her humerus. It was reported the resident was to wear a sling at all times to allow the bone to heal. It was reported on the discharge paperwork the resident was discharged to a Skilled Nursing Facility (SNF). Administrator will send a copy of the coroners report to LPA Benson. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report was given to Administrator.the state’s words, verbatim · CDSS document, Nov 3, 2025

Allegation investigated: Staff does not ensure facility is free of bed bugs.

On September 4, 2025 at approximately 3:30 PM, Licensing Program Analyst (LPA), Sarah Benson arrived unannounced at Hilltop Springs Senior Living for the purpose of opening a complaint investigation. LPA was greeted at the door by Administrator Tracy Lehner and was granted access into the facility. During the opening of the complaint, LPA conducted a interview with Administrator. LPA Benson and Administrator Tracy Lehner toured the facility. The Administrator stated a resident living in the Independent Living area had reported finding bed bugs. The apartment has been treated by a professional pest control. The Administrator reported the incident was isolated with no further signs of bed bugs at the facility. The resident is not living in the assisted living or memory care area. LPA Benson will cross report with the county health department. This agency has investigated the complaint allegations. We have found the complaint was Unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview was conducted and a copy of this report was signed and given to the Administrator Unfoundedthe state’s words, verbatim · CDSS document, Sep 4, 2025 · control 59-AS-20250903091335

Type of visit: Case Management - Incident

On 8-14-25 at 10:00am Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Tracy Lehner and explained the reason for the visit. The department is following up on Incident Report (IR) submitted by the facility on 07-30-25 stating that resident, R1 had a fall resulting in a fractured left hip which was diagnosed on 7-30-25. Staff reported finding R1 on the ground at 8:55pm in the middle of her living room. Staff called EMS for an evaluation. Staff reported sending R1 to the hospital. R1's doctor ordered lab work and X-RAY with results of fractured left hip. Department conducted interviews with the administrator and nurse regarding this incident. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report given to Administrator.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Other

On 7-29-25 at 12:30pm Licensing Program Analyst LPA Sarah Benson arrived unannounced at the facility to complete the annual inspection started on 7-25-25. LPA Benson met with Administrator Tracy Lehner. During todays visit files were reviewed. The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report, and appeal rights provided to administrator. See annual inspection dated 2025.the state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Required - 1 Year

On 07/25/2025 at 1:00pm Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Tracy Lehner (cert #7005595740 Exp:8-21-26) and explained the purpose of the visit. Administrator certificate is current. LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to five (5) resident rooms, common areas, five (5) bathrooms, kitchen, storage areas and yard. Staff and resident files were reviewed. Not able to complete files review. Medications were also reviewed. Deficiencies were observed. Medication is locked in a locked closet. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, lighting and windows with screens. The bathrooms were clean and in good repair. Deficiencies were observed. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility. The pools/bodies of water on the premises is locked with the only entrance to use a key fob. No firearms are on premises. The last disaster drill was conducted and documented on 7-22-25, the facility has been conducting drills every 3 months. LPA interviewed three residents and three staff. The annual inspection was not completed due to time restraints. LPA will return to complete this inspection. The document was signed and a copy delivered to the Administrator. On 7-29-25 LPA Benson arrived at 12:30pm and completed the annual inspection with the CARES tool. The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report, and appeal rights provided to administrator.the state’s words, verbatim · CDSS document, Jul 25, 2025

Allegation investigated: 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.

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 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. 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. 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. 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.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 59-AS-20240813110806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87707(2)(B) · Plan of correction due date: Mar 11, 2025

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. 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.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 11, 2025

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… 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.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Mar 11, 2025

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. 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.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 11, 2025

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. 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.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Mar 11, 2025

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. 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.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: The administrator agrees to have the call system inspected by a professional and shall send the invoice to the licensing agency.

Type of visit: Case Management - Incident

On February 24, 2025 at approximately 1:15 PM, Licensing Program Analysts (LPA), Farhaan Sarangi and Kayla Adkison arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Managemen-Incident Inspection. LPAs met with the Assistant Executive Director, Olivia Brady and was granted access into the facility. LPAs toured the facility and observed the facility to be clean with all exits free from obstruction. LPAs observed sufficient perishable and non-perishable foods located in the kitchen. All three floors of the facility were observed to be in Title 22 compliance. On January 17, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident fell multiple times in the span of a couple of weeks. Memory Care Director reported that the Primary Care Physician was notified and the Care Plan was reviewed and updated accordingly. Resident is reportedly doing good at this time with no falls since January 2025. On January 22, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident had an unwitnessed fall and was found on the bathroom floor of the residents room. Administrator reported that the Primary Care Physician was notified and the Care Plan was reviewed and updated accordingly. Facility has since moved the resident to the Memory Care Unit and the resident is doing good at this time with no new falls since being in the Memory Care Unit On January 27, 2025, Community Care Licensing Division (CCLD) received an SOC 341 indicating that a resident was being verbally aggressive. The Caregiver on duty that day took the television privileges away from the resident. Administrator terminated the alleged Caregiver immediately and conducted staff training. LPA advised that if another incident of this same nature occurs again, a citation would be issued to the facility for Personal Rights. Administrator conducted staff training surrounding Personal Rights. (Report continued on LIC 809C) LPA advised that if another incident of this same nature occurs again, a citation would be issued to the facility for Personal Rights. Administrator conducted staff training surrounding Personal Rights. On January 28, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident had 14 falls. Facility staff reported that she is a two person transfer. Primary Care Physician has been notified and the Care Plan has been updated. LPAs observed the room to ensure it is safe for the resident in care. LPAs observed the room to be in Title 22 Compliance. On February 11, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident had an unwitnessed fall in which the resident sustained a leg fracture. Primary Care Physician was notified regarding the fall and fracture. Facility staff reported that the resident has since went to rehab and will transition back to the facility. Facility has not heard when the resident will be discharged back to the facility. No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted, and a copy of this report was signed and given to Assistant Executive Director.the state’s words, verbatim · CDSS document, Feb 24, 2025

Type of visit: Office

On January 8, 2025, at approximately 10:00 AM, an informal conference was conducted with Hilltop Springs Senior Living at the Chico Regional Office. The purpose of this informal conference meeting is to discuss the deficiencies observed within last year and to address current issues at facility. Present in the meeting were, Licensing Program Manager (LPM) Lauren Crocker, Licensing Program Analysts (LPAs) Farhaan Sarangi, Kayla Atkinson, Administrator, Keila O’Farrell, District Operations Support, Darrion Brown, Director of Operations, Matt Dunham, Licensee, Doug Sproul, Health and Wellness Director, Lorena Kott. The Administrator was told that this Informal conference is a part of the Administrative Action process, and that further non-compliance may result in an elevation to a formal non-compliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The informal conference process was explained during this meeting. Issues discussed during the meeting were: Issues discussed during the meeting were: - The Volume of complaints received in the last 6 months - Two incidents of residents eloping - Background Clearances - Medication Management - Staff training - Needs and supervision of residents During the Informal Conference, the facility has stated they will do the following to achieve continued and substantial compliance: • Reach out to Community Care Licensing Division (CCLD) as a resource. · Send facility program updates to the Regional Office · Community Care Licensing Division Technical Support Program (TSP) was offered and accepted. No deficiencies were cited during today’s Office Visit. Exit interview was conducted. Informal meeting concluded, copy of the Office Visit was signed and provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Case Management - Incident

On January 7, 2025 at approximately 1:15 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Managemen-Incident Inspection. LPA met with the Administrator, Keila O'Farrell and District Operations Support, Darrion Brown. On January 6, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident fell and sustained a fracture. Administrator will be performing a reappraisal and updating the Care Plan. No deficiencies were observed or cited during today's Case Management-Incident Inspection. Exit interview was conducted, and a copy of this report was signed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jan 7, 2025

Allegation investigated: Staff caused injuries to resident in care. Staff did not ensure resident was fed. Staff mismanaged resident's medications. Staff did not answer resident's call button in a timely manner. Staff did not ensure resident's room was cleaned and sanitized. Staff are not properly trained to transfer residents. Staff did not report incidents to resident's responsible party.

On December 02, 2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Administrator, Keila O'Farrell and was granted access into the facility. During the course of the investigation, LPA reviewed facility records, resident records, interviewed staff, witnesses and a collateral interview with Resident #1. Complaint alleges that Staff caused injuries to resident in care and Staff did not report incidents to resident's responsible party. Based on an observation of facility records, resident records and interviews that were conducted with 4 witnesses which included two doctors and two home health nurses, LPA received inconsistent statements. (Report continued on LIC 9099C) Unsubstantiated During an interview with Resident #1, LPA learned that during one incident, staff was assisting the resident out of bed when the resident slipped and fell on the guardrails. During this incident, Resident #1 could not identify the date, time and/or the staff members involved with the assistance. A review of an incident report dated for September 17, 2024, reflected that the resident fell and that the Responsible Party was notified of this fall. In addition, LPA reviewed an additional incident report dated for September 20, 2024, which reflected the residents change of condition. Furthermore, LPA could not corroborate the allegations. Complaint alleges that Staff did not ensure resident was fed. Based on observation of facility records, resident records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during an interview with Resident #1, LPA learned that the resident would eat three times a day and would order food, and that staff would drop it off in the room. During a review of the Progress Notes on October 24, 2024, LPA observed in the notes that the resident had to be reminded to eat food. Furthermore, LPA could not corroborate the allegation. Complaint alleges that Staff mismanaged resident's medications. Based on observation of facility records, resident records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during a collateral interview with Resident #1, LPA received inconsistent statements as it relates to the amount that was given. During the opening of the complaint on October 4, 2024, LPA reviewed the Medication Administration Record (MAR) and the Medication Order for the medication in question, LPA did not observe any discrepancies. Furthermore, LPA could not corroborate the allegation. Complaint alleges that Staff did not answer resident's call button in a timely manner. Based on observation of facility records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during a review of the call button history, LPA observed no calls exceeding one hour as initially reported. LPA could not corroborate the allegation. Complaint alleges that Staff did not ensure resident's room was cleaned and sanitized. Based on observation of facility records and interviews that were conducted, LPA received inconsistent statements. Furthermore, during a collateral interview with Resident #1, Resident reported that the staff members cleaned the room. LPA could not corroborate the allegation. (Report continued on LIC 9099C Complaint alleges that Staff are not properly trained to transfer residents. Based on observation of facility records, LPA received inconsistent statements. Furthermore, during a review of staff training records on December 02, 2024, LPA observed sufficient training hours as outlined in Title 22 Regulations. LPA could not corroborate the allegation. A finding that the complaint allegations of Staff caused injuries to resident in care, Staff did not ensure resident was fed, Staff mismanaged resident's medications, Staff did not answer resident's call button in a timely manner, Staff did not ensure resident's room was cleaned and sanitized, Staff are not properly trained to transfer residents and Staff did not report incidents to resident's responsible party are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2024 · control 59-AS-20241003084921

Allegation investigated: Unqualified staff is providing care and supervision. Uncleared individuals are allowed stay on the facility grounds. Staff are mishandling the residents medications. Staff are not meeting the residents needs while in care. Staff do not properly safeguard the facility grounds. Staff do not provide adequate food service. Facility not providing basic laundry services to residents.

On December 2, 2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of opening and delivering complaint findings. LPA was greeted at the door by Administrator, Keila O'Farrell, and was granted access into the facility. During the opening of the complaint, LPA interviewed the Administrator and a random sample of residents in care. In addition, LPA reviewed staff files and a resident file. Complaint alleges that unqualified staff is providing care and supervison. Based on interviews that were conducted and an observation of facility training, LPA could not prove or disprove the allegation. On December 2, 2024, LPA conducted a staff file review which included staff training on a random sample of staff members, LPA reviewed staff training and found no discrepancies in staff training. LPA could not corroborate the allegation. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges that Uncleared individuals are allowed stay on the facility grounds. Based on observation of the Guardian Background Clearances and a tour of the facility, LPA could not prove or disprove the allegation. Furthermore, during a tour of the facility, LPA checked ALL staff that were working at the facility. All staff that were present have background clearances as outlined in Title 22 regulations. LPA could not corroborate the allegation. Complaint alleges that Staff are mishandling the residents medications. Based on interviews that were conducted and a review of a resident medication, LPA could not prove or disprove the allegation. LPA conducted a review of the Medication Administration Record (MAR) for Resident #1 for the dates of February 2024 through September 2024 and observed no concerns. Furthermore, LPA conducted interviews and received inconsistent statements as it relates to the allegation. LPA could not corroborate the allegation. Complaint alleges that Staff are not meeting the residents needs while in care. Based on interviews that were conducted with a random sample of residents in care, LPA could not prove or disprove the allegation. Furthermore, during interviewing with residents, LPA learned of no concerns. LPA could not corroborate the allegation. Complaint alleges that Staff do not properly safeguard the facility grounds. Based on an observation during the tour of the facility on December 2, 2024, LPA could not prove or disprove the allegation. Furthermore, during said tour, LPA observed the facility to be safe and secure. During interviews with a random sample of residents in care, LPA learned of no concerns and that the residents feel safe, secure and sleep well at night. Complaint alleges that Staff do not provide adequate food service. Based on observation of the food service at the facility on December 2, 2024, LPA could not prove or disprove the allegation. LPA observed kitchen staff making food and residents consuming food that was made by kitchen staff in the dining room. In addition, LPA conducted a tour of the Memory Care Unit and found that residents were eating hot food from a Cambro Cart which keeps the food hot. LPA inspected a plate of food and observed the food to be hot to the touch. During an interview with a random sample of residents, LPA received inconsistent statements as it relates to the allegation and also could not corroborate the allegation. (Report continued on LIC 9099C) Complaint alleges that Facility not providing basic laundry services to residents. Based on interviews that were conducted, LPA received inconsistent statements as it relates to the allegation. Furthermore, LPA toured the laundry room and observed that the laundry was being completed by staff members that were on shift. LPA could not corroborate the allegation. A finding that the complaint allegations of: Unqualified staff is providing care and supervision, Uncleared individuals are allowed stay on the facility grounds, Staff are mishandling the residents medications, Staff are not meeting the residents needs while in care, Staff do not properly safeguard the facility grounds, Staff do not provide adequate food service and Facility not providing basic laundry services to residents are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2024 · control 59-AS-20241028125940

Type of visit: POC

On December 2, 2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Plan of Correction (POC) inspection LPA was greeted at the door by Administrator, Keila O'Farrell, and was granted access into the facility. LPA reviewed the POC and cleared the citation. No deficiencies were observed or cited during today's POC inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2024

Allegation investigated: Facility did not report scabies outbreak at facility

On October 21, 2024 at approximately 10:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of opening a complaint and deliering complaint findings. LPA was greeted at the door by Administrator, Keila O'Farrell, and was granted access into the facility. During the opening of the complaint, LPA interviewed the Administrator and requested an email from the Local Public Health Authority and the facility Administrator. Complaint alleges that Facility did not report scabies outbreak at facility. Based on a review of Community Care Licensing Division (CCL) incident reports, LPA learned that the incident report was sent in a timely manner and within Title 22 Regulations Reporting Requirements. Furthermore, the date that the incident occurred was on October 3, 2024, and the date the incident report was sent to CCL was on October 4, 2024. (Report continued on LIC 9099C) Unsubstantiated In addition, LPA learned that the facility did report to the Local Public Health Authority on October 3, 2024. A finding that the complaint allegation of Facility did not report scabies outbreak at facility are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 59-AS-20241015100310

Type of visit: Case Management - Deficiencies

On October 21, 2024 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Management-Deficiencies inspection. During the Case Management-Deficiencies inspection, LPA reviewed the LIC 602 for Resident #1. Based on a review of the LIC 602, LPA learned that the resident is not allowed to leave the facility unassisted. However, the resident eloped from the facility and was found 3 miles away at the Best Buy. LPA educated the Administrator on the importance of ensuring that safety measures are put in place to address the wandering/elopement of residents in care. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 22, 2024

87705(b)(2) Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by: Based on a review of the LIC 602, Resident #1 is unable to leave the facility unassisted which presents an immeidate health, safety and personal rights risk to the resident(s) in care.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: Administrator/Licensee shall conduct staff training and provide proof of training. In addition, facility shall submit an LIC 9098-Self Certication and a plan for future compliance. POC Due Date: 10/22/2024

Type of visit: Case Management - Deficiencies

10/15/24 10:15 AM Licensing Program Analyst (LPA) Rebecca Knight conducted a case management visit to follow up on an issue that was reported to Donna Gurriere, LPA on 10/08/24. During a walk through of the memory care unit, LPA Gurriere spoke to a resident from the assisted living side of the facility who was visiting his wife in the memory care unit. LPA Gurriere asked the resident how he was doing, and he replied that everything was fine except for his wife’s laundry was not getting done. When asked why the laundry wasn’t getting done, he replied, “It was due to, well you know, the scabies outbreak.” He indicated that his wife was upset because her laundry was not getting done. While gathering information of the scabies outbreak, LPA Gurriere was advised that at least two residents have scabies, and several other residents have a “rash.” It was reported that the residents that have a rash have not been diagnosed or been seen by a physician at this time. Residents were observed mingling with one another, one care provider was giving pedicures to three residents, which could have increased the spread of scabies using the same utensils and gloves on each of the resident’s toes. Of concern is that the resident that was visiting his wife in memory care, could carry the scabies outbreak to the assisted living side of the facility where he resides. Facility staff included the care provider giving pedicures and one medication technician for 13 residents diagnosed with dementia. Continued on LIC809-C The facility will be cited this date for the scabies outbreak and for not having enough staff to take the necessary precautions to prevent the spread of scabies. Sufficient staff were not present to ensure that the residents were taken to their physician for medical issues (rashes) and the laundry was not being completed to assist in the potential spread of scabies. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC809D. Upon inspection of the facility’s compliance history, LPA determined that the licensee was issued a deficiency for the same violation within the past 12 months. As a result, a civil penalty was assessed in the amount of $250.00 on 10/15/2024 on the attached LIC421. 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, additional civil penalties may be assessed.the state’s words, verbatim · CDSS document, Oct 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 29, 2024

87468.1(a)(2) Personal Rights - To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidenced by: Based on an interviews and observations the Licensee/Administrator did not ensure that there was not a spread of scabies in the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: The administrator agrees to submit a plan of correction to the licensing agency advising of the resident names of those that have scabies or a rash; a list of residents that need to see their physician and when, a step-by-step plan on how the facility will rectify the scabies outbreak and a plan to follow universal precautions as outlined in 87211(a)(1)(D). Plan of correction is to be submitted to CCLD by 10/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Oct 29, 2024

87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment, and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews and observations the Licensee/Administrator did not ensure that there were enough staff present to ensure that the residents were seen by their physicians to be treated for the rashes, the spreading of scabies and the laundry being completed. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Licensee/Administrator agrees to submit an understanding of the regulation. In addition, Licensee and Administrator shall hire additional staff in the Memory Care Unit and/or staff appropriately to meet the needs of the residents that the facility serves. Licensee/Administrator shall provide a statement on how they will meet the staffing to resident ratio. In addition the administrator agrees to submit a list of staff persons names working in the memory care unit. The administrator shall provide training to all staff by a skilled professional on universal precautions when dealing with a scabies outbreak and shall submit to the licensing agency a signed list by staff persons that received the training. Plan of correction is to be submitted to CCLD by 10/29/2024.

Allegation investigated: Not enough staff to meet resident needs Facility staff not reporting incidents

On October 1, 2024 at approximately 08:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Keila O'Farrell, and was granted access into the facility. During the course of the investigation, LPA reviewed facility records, resident records, interviewed staff and witnesses. Resident could not be located for an interview. Complaint alleges that Not enough staff to meet resident needs. Based on interviews that were conducted with witnesses and staff, the preponderance of evidence standard has been met. LPA conducted interviews with staff and learned that the facility does not have enough staff members in the Memory Care Unit to meet the needs of the resident population that is served. Witnesses that observed not enough staffing has corroborated this allegation. (Report continued on LIC 9099C) Substantiated Complaint alleges Facility staff not reporting incidents. Based on observation of incident reports, LPA observed that the facility did not submit incident reports in a timely manner. During a facility file review, LPA observed internal incident reports that the facility had but never submitted those incident reports to Community Care Licensing Division. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights. A finding that the complaint allegation of Facility staff ignoring residents are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administratorthe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 59-AS-20240910141106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 2, 2024

87411(a)- Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews conducted with staff, the facility does not have enough staff members in the Memory Care Unit to meet the needs of the resident. Witnesses observed not enough staffing which presents an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Licensee/Administrator to submit an LIC 9098 understanding of the regulation. In addition, Licensee and Administrator shall hire additional staff in the Memory Care Unit and/or staff appropriately to meet the needs of the residents that the facility serves. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: October 2, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 8, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on observations of incident reports, facility did not submit incident reports in a timely manner. During a facility file review, LPA observed internal incident reports that the facility had but never submitted those incident reports to Community Care Licensing Division which is a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Licensee/Administrator to submit an LIC 9098 understanding of the regulation. In addition, Licensee and Administrator shall conduct staff training outlining Reporting Requirements. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: October 8, 2024

Allegation investigated: Facility is serving under cooked meat

On October 1, 2024 at approximately 09:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of opening a complaint. LPA was greeted at the door by Administrator, Keila O'Farrell and was granted access into the facility. During the course of the investigation, LPA interviewed staff and a random sample of residents. In addition, LPA conducted a tour of the kitchen and made observations. Complaint alleges that facility is serving under cooked meat. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, an interview with a random sample of residents could not corroborate the allegation. During a tour of the facility, LPA observed chefs preparing food in a clean kitchen and wait staff serving the food to residents in care. (Report continued on LIC 9099C) Unsubstantiated A finding that the complaint allegation of Facility is serving under cooked meat are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administratorthe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 59-AS-20240930143721

Type of visit: Case Management - Deficiencies

On September 24, 2024 at approximately 10:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Managemen-Deficiencies Inspection. LPA met with the Administrator, Keila O'Farrell. On September 20, 2024, Med Tech was training another staff member when residents were administered medication in the dining room. Resident that received the medication from the staff member trainee was wrong. The trainee noticed the medication error and brought this up to the Med Tech. Primary Care Physician and Responsible Party were notified. On September 23, 2024, a resident requested a pain pill and then was given the wrong medication. Med Tech observed the error during checks. Primary Care Physician and Responsible Party were notified (See LIC 809D). LPA educated the Administrator on the importance of ensuring that all residents are given the correct dosage of medications per physician orders. LPA advised to send both incident reports to Community Care Licensing Division (CCLD). Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Sep 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(b) · Plan of correction due date: Sep 25, 2024

87465(b) Incidental Medical and Dental Care (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement was not met as evidenced by: Based on interviews with the Administrator, there were two incidents of Medication Errors that occured on September 20, 2024 and September 23, 2024 which is an immeidate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee shall submit an LIC 9098-Self Certification. In addition, Licensee shall conduct staff training with ALL staff. Licensee/Administrator provide a statement on how future compliance will be met. Plan of Correction due date: September 25, 2024.

Type of visit: POC

On September 19, 2024 at approximately 12:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Plan of Correction Inspection. LPA was greeted at the door by Administrator, Keila O'Farrell, and was granted access into the facility. Also present was, Assistant Administrator, Jessica Martensen. LPA reviewed the entire Plan of Correction and found that to be appropriate. LPA cleared the citations and issued the POC letters. No deficiencies were observed or cited during today's Plan of Correction Inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Case Management - Incident

On September 19, 2024 at approximately 12:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Managemen-Incident Inspection. LPA met with the Administrator, Keila O'Farrell and Assistant Administrator, Jessica Martensen. On September 10, 2024, Community Care Licensing Division (CCLD) received an incident report indicating that a resident was stuck in a elevator for 30-40 minutes. The resident was panicking when the incident occurred. The elevator was serviced that same day. LPA toured the facility which included the tour of where the elevator is located. LPA took a ride on the elevator and observed no concerns with the movement of the elevator and the opening of the elevator doors. LPA reviewed the Elevator Permit and found that to be appropriate. The Elevator Permit was issued on June 2024. LPA attempted to interview the resident in care but was unsuccessful. Resident was out of the facility on an outing. LPA requested the following document: -Receipt of elevator servicing No deficiencies were observed or cited during today's Case Management-Incident Inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 19, 2024

Allegation investigated: Medication left accessible to resident in care Facility ran out of medication for resident Resident was found sleeping on soiled sheets Resident fell and was not checked on after the fall Resident was over-charged Facility staff falsified documentation

On September 9, 2024 at approximately 02:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA met with Administrator, Keila O'Farrell. During the course of the investigation, LPA reviewed resident records, interviewed the former resident and staff. In addition, LPA made observations and toured the facility on July 15, 2024. Complaint alleges that Medication left accessible to resident in care. Based on the interviews that were conducted, LPA received inconsistent statements and could not corrborate the allegation. Furthermore, during an interview with Resident #1, LPA learned that the facility dispensed medication to Resident #1 and does not recall medications being left in the room. Complaint alleges that Facility ran out of medication for resident. Based on the interviews that were conducted with staff and Resident #1, (Report continued on LIC 9099C) Unsubstantiated Furthermore, Nurse also admitted to the allegation being true (See LIC 9099D). Complaint alleges Reporting Requirements. Based on an interview with the Nurse on July 15, 2024, LPA received consistent statements which meets the preponderance of evidence standard. Furthermore, during the interview with the nurse, LPA learned that the facility did not report this incident and that the facility did not follow Reporting Requirements. LPA educated the Administrator on the importance of ensuring that all reportable incidents are reported to Community Care Licensing Division (CCLD) (See LIC 9099D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator. LPA received inconsistent statements and could not corroborate the allegation. Furthermore, during an interview with Resident #1, LPA learned that the facility filled the script timely when it was ready by the pharmacy. Complaint alleges that Resident was found sleeping on soiled sheets. Based on an interview that was conducted with Resident #1, LPA received inconsistent statements. Furthermore, during a tour of the facility on July 15, 2024, LPA observed residents to be appropriately dressed and free from continence. Facility and the resident bedrooms were found to be clean. LPA toured a sample of resident bedrooms which were observed to be appropriate and smelling good. Complaint alleges Resident fell and was not checked on after the fall. Based on an interview that was conducted with Resident #1, LPA received inconsistent statements as it relates to the allegation. Furthermore, Resident #1 acknowledged of falling and being checked on by facility staff after the fall occurred. Complaint alleges that Resident was over-charged. The Department's Auditor from the Investigations Branch reviewed the allegation and associating documents which includes the billing related to the allegation and found that the resident was not overcharged for the care and services that were being provided by the facility. The report also noted that the resident received a refund after discharge due to the rent being paid in advance. Complaint alleges Facility staff falsified documentation. Based on interviews that were conducted, LPA received inconsistent statements. Facility staff have denied falsifying documentation. In addition, during a review of Resident #1's record, LPA reviewed documents and could not find any evidence that the facility was falsifying documents. A finding that the complaint allegations of Medication left accessible to resident in care, Facility ran out of medication for resident, Resident was found sleeping on soiled sheets, Resident fell and was not checked on after the fall, Resident was over-charged and Facility staff falsified documentation are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 9, 2024 · control 59-AS-20240712100825

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Sep 10, 2024

87465(a)(6): (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by: Based on an interview with the Nurse, LPA received consistent statements as it relates to the medication not being administered per MD orders. Furthermore, during a review of the Medication Administration Record on July 15, 2024, LPA observed that medication administration was missed on December 26, 2023 and December 28, 2023 for Resident #1 which presents an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2024

Plan of correction: Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to ensuring that Title 22 regulations are being followed at the facility. Furthermore, Licensee shall submit a plan for future compliance. POC Due Date: September 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(d) · Plan of correction due date: Sep 17, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on an interview that was conducted with the Nurse on July 15, 2024, the Department received no incident report for a reportable incident which presents a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2024

Plan of correction: Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to ensuring that Title 22 regulations are being followed at the facility. Furthermore, Licensee shall submit a plan for future compliance. POC Due Date: September 17, 2024

Allegation investigated: Resident is eloping due to lack of supervision Facility is not safeguarding resident’s personal items Medication mismanagement

On September 5, 2024, at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Keila O'Farrell, and was granted access into the facility. During the course of the investigation, LPA reviewed resident records, interviewed the residents in care and staff. In addition, LPA made observations and toured the facility on August 6, 2024. Complaint alleges Resident is eloping due to lack of supervision. Based on review of incident reports from April 25, 2024, LPA learned that there were two residents that were identified as eloping from the facility but returned to the facility and back into placement the same day (See LIC 9099D). Furthermore, during an interview with the Administrator on August 6, 2024, LPA learned that the resident in question has eloped in passing due to an issue with the egress door during said date of elopement. The egress door was fixed in June 2024. (Report continued on LIC 9099C) Substantiated Complaint alleges that facility is not safeguarding resident’s personal items. During the investigation, LPA interviewed staff and learned that a pair shoes that belonged to the resident went missing and could not be found. LPA was made aware during an email conversation on August 7, 2024, the Administrator disclosed that the facility ordered a new pair of shoes for the resident. LPA educated the Administrator on ensuring that Safeguards for Resident Cash, Personal Property, and Valuables are being implemented throughout the facility as outlined in Title 22 regulations (See LIC 9099D). Complaint alleges Medication mismanagement. Based on a record review of a random sample of residents in care, the preponderance of evidence standard has been met regarding the facility mismanaging resident’s medications (See LIC 9099D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator. A finding that the complaint allegation of Facility is not meeting resident’s needs resulting in repeated UTIs are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 59-AS-20240806104318

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 6, 2024

87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on record review of incident reports, LPA was able to identify two residents that eloped from the facility in April 22, 2024, which presents an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to elopement Procedures. Furthermore, Licensee shall submit a plan for future compliance and a facility roster to reflect appropriate staffing is available to residents in care. POC due date: September 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 6, 2024

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on a record review of a random sample of residents in care, the preponderance of evidence standard has been met regarding the facility mismanaging resident’s medications which presents an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to ensuring that Title 22 regulations are being followed at the facility. Furthermore, Licensee shall submit a plan for future compliance. POC due date: September 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Sep 12, 2024

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents’ cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidenced by: Based on interviews that were conducted on August 7, 2024 with the Administrator, a pair of shoes went missing that could not be found and that the facility had to purchase new shoes for the resident in care which presents a potential health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to Safeguards for Resident Cash, Personal Property, and Valuables. Furthermore, Licensee shall submit a plan for future compliance. POC due date: September 12, 2024

Allegation investigated: Untrained staff administering medications Staff dispensed wrong medications for resident on an outing causing resident to miss medications

On September 5, 2024, at approximately 09:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Keila O'Farrell and was granted access into the facility. During the course of the investigation, LPA reviewed resident records, interviewed a resident in care and the Administrator. Complaint alleges that Untrained staff administering medications. Based on interviews that were conducted, LPA could not prove or disprove the above allegation. Furthermore, LPA received inconsistent statements during the investigation. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges that Staff dispensed wrong medications for resident on an outing causing resident to miss medications. Based on interviews that were conducted, LPA could not prove or disprove the above allegation. LPA learned that the resident’s significant other was handling this particular medication. Furthermore, inconsistent statements were made during the investigation. A finding that the complaint allegations of Untrained staff administering medications, Staff dispensed wrong medications for resident on an outing causing resident to miss medications are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 59-AS-20240812144823

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 6, 2024

87465(a)(4) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews that were conducted, the Administrator was aware that medications have not been refilled by the facility which presents an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to ensuring that Title 22 regulations are being followed at the facility. Furthermore, Licensee shall submit a plan for future compliance. POC due date: September 6, 2024

Allegation investigated: Licensee allows uncleared staff to provide care for residents

On September 5, 2024 at approximately 09:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi conducted an unannounced complaint investigation inspection for the purpose of opening a complaint. LPA met with Administrator, Keila O'Farrell. During the opening of the complaint, LPA toured the facility and made observations on September 5, 2024. In addition, LPA interviewed the Administrator. Complaint alleges that Licensee allows uncleared staff to provide care for residents. Based on an interview with the Administrator, LPA learned that the facility just recently hired the staff member to work on the Independent Living side of the facility that is also connected to the Assisted Living side of the facility. LPA conducted a tour of the 1st floor of the facility on September 5, 2024 at approximately 09:00 AM and observed the uncleared staff member cooking food (See LIC 9099D). (Report continued on LIC 9099C) Substantiated LPA educated the Administrator on the importance of ensuring that ALL staff have a Criminal Record Clearance as outlined in Title 22 Regulation 87355(a). Furthermore, a review of the Guardian Background Clearance list on September 5, 2024, reflects that the newly hired staff is "In Process" of obtaining a Background Clearance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Civil Penalty in the amount of $100.00 was issued for the Uncleared Adult. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 59-AS-20240903081337

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(a) · Plan of correction due date: Sep 6, 2024

87355(a) Criminal Record Clearance: (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement was not met as evidenced by: Based on an interview with the Administrator and a tour of the facility, the uncleared adult was just recently hired to work on the Independent Living side of the facility that is also connected to the Assisted Living side of the facility. LPA conducted a tour of the 1st floor of the facility on September 5, 2024 at approximately 09:00 AM and observed the uncleared staff member cooking food which is an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Licensee/Administrator shall submit an LIC 9098 understanding of the regulation. Furthermore, Licensee/Administrator shall submit a statement regarding a plan for future compliance. POC Due Date: September 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87761(b) · Plan of correction due date: Sep 6, 2024

87761(b) Penalties (b) Notwithstanding Section 87761(a) above, an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1569.17(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 87355(e) prior to working, residing or volunteering in the facility. Civil Penalty assessed in the amount of $100.00.the state’s words, verbatim · CDSS document, Sep 5, 2024

Type of visit: Case Management - Incident

On September 5, 2024 at approximately 09:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting an Case Management-Incident Inspection. Upon arrival, LPA was greeted outside by Administrator, Keila O'Farrell and was granted access into the facility. During the Case Management-Incident Inspection, pertaining to the incident report dated for July 27, 2024, Administrator reported that Resident #1's Responsible Party was adamant of keeping the resident in Assisted Living instead of Memory Care when the resident moved in to the facility in May 2024. However, the Change of Condition happened when the resident walked passed the supermarket in late July 2024, and that is when the conversation of admitting the resident to Memory Care Unit. Administrator followed-up with the family multiple times and that the main priority was to keep the resident safe. Responsible Party agreed to place the resident in the Memory Care Unit after the elopement. On July 24, 2024, the facility reported that Resident #2 had a hip fracture while on hospice attempting to get up from the chair in the common area. The incident report reflects that the resident was last seen in the common area before the unwitnessed fall. Subsequently, resident got transferred to the hospital after the fall. Facility was conducting more frequent room checks when the resident returned back to the facility. Resident was on comfort care and was on hospice up until the discharge on August 9, 2024. On July 10, 2024, the facility reported that Resident #3 when the fall happened the resident was making the bed when the unwitnessed fall occurred. Resident fell, pressed pendent and was subsequently attended to by a staff member. No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this signed report was given to the Administrator.the state’s words, verbatim · CDSS document, Sep 5, 2024

Type of visit: Required - 1 Year

On 06/18/2024 09:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Keila OFarrell Administrator and explained the purpose of the visit. Administrator is waiting for certificate from Administration Certificate unit. LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet. The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility. The pools/bodies of water meet regulation standards. No firearms are on premises. The last disaster drill was conducted and documented on 5-13-24, the facility has been conducting drills every month. The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report, and appeal rights provided to administrator.the state’s words, verbatim · CDSS document, Jun 18, 2024

Allegation investigated: Staff do not ensure that residents' medications are disposed of from the facility. Staff do not store residents' medications locked and inaccessible to residents. Staff do not conduct audits of residents' narcotic medications.

On 4-25-24 at 3:45PM, Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 02/22/24. LPA Benson met with Heather Newcom General Manager, Susan Mosby Health Service Manager, Lacey Mcdermoth Resident Care Cordinatior and explained the purpose of the visit. Continued on 9099-C Unsubstantiated Staff do not ensure that residents' medications are disposed of from the facility. During the interview process, documents were obtained to include the medication room audit, MAR/Narcotics weekly audit for five weeks and the centrally stored medications destruction document. During the investigation process, the administrator, the resident care coordinator and three staff persons related to the medication room were interviewed. In addition, LPA Boyles toured the medications room for a medication review with the administrator and the resident care coordinator. LPA Boyles reported that she observed the medications that were waiting to be destroyed. The administrator reported that sometimes there is a delay in destroying medication because as their policy states, two nurses must be present. The administrator reported that sometimes due to competing demands, medication destruction is not prioritized and is rescheduled. However, medication is destroyed within the parameters outlined within the program plan. Staff do not store residents' medications locked and inaccessible to residents. During the investigation process, the administrator, the resident care coordinator and three staff persons related to the medication room were interviewed. In addition, LPA Boyles toured the medications room for a medication review with the administrator and the resident care coordinator. It was reported by LPA Boyles that all medications were locked and inaccessible to residents. During the interview process none of the persons interviewed indicated that they have seen medications unlocked. Staff do not conduct audits of residents’ narcotic medications. During the investigation process all staff indicated that the residents’ narcotic medications are audited daily with a two-person review. In addition, documents were received of the medication room audit and MAR/Narcotics weekly audit for five weeks. During the interviews and documents reviewed, there was no indication that staff do not conduct audits of residents narcotic medications. 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 all of the above findings are Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 59-AS-20240222082958

Allegation investigated: Uncleared staff are working at the facility.

On 01/23/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 11/09/23. LPA Gurriere met with , Susan Mosby, Health Services Manager and explained the purpose of the visit. Uncleared staff are working at the facility. During the interview process, a walk-through of the facility was conducted, and nine staff files were reviewed. In addition, the administrator, four staff persons and three residents were interviewed. continued Substantiated During the investigation, documents were obtained and reviewed to include the Staff Records Review document, staff names and cell numbers and the staff listed on the Guardian Roster Report. During the walk-through staff were present and a review of their fingerprint clearances and associations were determined. Nine staff person records were reviewed and out of the nine staff persons, three were not associated with the Hilltop Springs Senior Living facility. Although the three staff members were either cleared or pending clearance, the three staff members were associated to the facility’s sister facility in southern California. It was reported that the facility was associating most of their staff through the sister facility; however, the administrator was advised during the visit that staff should be associated with the facility that they are working in. 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. 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. During the investigation, five staff training files were reviewed. Documents were obtained and reviewed to include Direct Care Staff Initial Orientation Training which indicates a checklist of 20 hours of training before working independently and 20 hours of training within the care providers first four weeks. A copy of the Certreo California RCFE Orientation Program is the training module that the licensee uses and “hands on” training is provided to the care providers. In addition, interviews were conducted and overall, it was stated that the staff persons have received adequate training to provide care for and supervision to the residents. Facility Kitchen is not maintained clean. During the facility walk through, the kitchen was observed. There were approximately five staff persons working in the kitchen preparing the lunch menu. The kitchen was observed to be clean, safe, and sanitary. There were no signs of rodent droppings or unsanitary conditions. The lunch menu was available and posted for the staff persons and for the residents. Facility food is not of good quality. During the facility walk through, dry food, refrigerated items and freezer items were observed. The facility was observed to have an abundance of bread, cookies, pastries, beef, chicken, fish, ham, vegetables, potatoes, turkey meat, cranberries, raisins, hash browns, gravy, biscuits, etc. The items appeared to be of high quality and were fresh. Facility does not provide an adequate activity program for the residents. During the walk through, the activities director was present. A calendar of activities was posted and available for residents. A copy of the calendar was provided to LPA Gurriere and had numerous daily activities to include Bridge, Pinochle, bible study, bowling, dominos, swimming, aerobics, fitness exercise, karaoke sing along, holiday party, poker night, etc. Special events this month include Greeting card making, gardening event, church carolers, art show, Shasta High Madrigal Singers, and a big band event. The facility provides a pool, a gym, and a bowling alley for the residents’ use. The activities director works 40 hours per week and has been employed since 06/03/23. During the walk through, three residents were interviewed. Two residents advised that they do participate in the activities; one resident was bowling during the visit. The third resident reported that she does not want to participate in the activities and that she knows that activities are provided if she changes her mind. Facility does not provide a safe environment for the residents. During the complaint intake, it was stated that there was a concern that the independent residents are mingling with the assisted living residents during pool time. Various pool activities are offered to the residents. The independent residents have a key "fob" that they use to enter the pool. The assisted living residents are required to have a care provider let them into the pool area. Dementia residents are not using the pool. The administrator indicated that there was one resident that likes to use the pool without care and supervision from a staff person. The facility is reminded that the facility shall follow regulation 87464(f)(1)(c) which states “Care and supervision means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered…” Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and all of the above findings are Unsubstantiated. During the investigation, the staff records were reviewed to include staff at the facility during the walk through and the management CEO team. All required records were available and in the facility files. There were no falsified staff records observed or found. Staff do not maintain residents’ records in an orderly fashion. During the investigation and walk through, the resident records five (5) were reviewed to include current residents residing at the facility. All records were available for review and were complete and in order, as required. Due to the information above, the Department finds the allegations to be Unfounded. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, copy of report provided.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 59-AS-20231109103951

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c)(1) · Plan of correction due date: Jan 24, 2024

Criminal Record Clearance - A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: A signed Criminal Background Clearance Transfer Request, LIC 9182. This requirement was not met as evidenced by: Based on interviews of staff persons and records reviewed, the licensee did not ensure that three staff persons were associated to the appropriate facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: The administrator agrees to submit to the licensing agency the transfer/criminal record clearance documents for the three staff persons listed. Facility is served a $1500.00 civil penalty for not having three staff persons associated to the Hilltop Springs Senior Living facility.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced on 10/20/23 to conduct a Health and Safety Inspection. LPA met with Administrator Simeon Purkey and explained the purpose of the visit. LPA and Administrator toured of the facility, LPA reviewed C1's LIC602, service plan, interim service plan and interviewed staff. C1 didn't have a history of leaving the facility and the facility had made arrangements and noted in interim service plan to perform hourly checks on resident after resident's spouse had been hospitalized. No deficiencies are found as a result of this visit. Report reviewed and copy provided Administrator Simeon Purkey.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Other

Amended Report for 9099 dated 08-24-23. On 10-13-23, Licensing Program Analyst LPA met with Heather Newcom general manager to discuss the amended report 9099 dated 08-24-23.. LPA Sarah Benson ask Health Newcom about keeping residents safe while leaving laundry soap available to residents in care. Heather Newcom stated the facility will keep the laundry soap in a locked area for the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2023