HILLTOP SPRINGS SENIOR LIVING

Official classification

Type B

Official code

1569.269(a)(5)

Regulation authority

HSC

What the official deficiency says

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.

Official 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.

Deadline recorded: Aug 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 counts, a resident was not given their medication as prescribed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/28/2026 Plan of Correction Licensee will conduct training with all med techs Licensee will conduct a in house medication review for all residents Licensee will sent proof of correction to LPA by POC due date.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

HSC

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jan 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above in three out of three showers had not slip-resistant mats or strips, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2025 Plan of Correction Staff will install slip strips in all residents rooms. Administrator will notify LPA when complete.

Official classification

Type B

Official code

87707(2)(B)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Oct 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Oct 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Sep 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(d)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87761(b)

Regulation authority

CCR

What the official deficiency says

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.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Sep 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in two out of two client's had expired medication dated 2-24 and 5-25, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2024 Plan of Correction Staff bought new MVI and destroyed the outdated alprazolam during LPA's inspection. Staff will implement weekly medication room audits. Staff will monitor centrally stored sheets. Staff will continue monthly med. tech meetings and present addition education for outdated medication at next meeting.

Official classification

Type A

Official code

87355(c)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jan 24, 2024. A deadline is not proof that correction was completed.