317000780-7-7-2023-59-AS-MSEY-CTMLY6-20230711090949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317000780
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:50:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2023 and conducted by Evaluator Angela Hood

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230620103846

FACILITY NAME:	GLADDING RIDGE		FACILITY NUMBER:	317000780
ADMINISTRATOR:	KRISTINE REYMONT		FACILITY TYPE:	740
ADDRESS:	1660 THIRD STREET		TELEPHONE:	(916) 645-0106
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	99	CENSUS: 41	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Kristine Reymont, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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-Staff handled residents in a rough manner
-Staff locked residents out of their bedrooms
-Staff spoke inappropriately to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Kristine Reymont, to deliver findings into the allegations listed above.

During the course of the investigation, interviews were conducted and documentation pertinent to the investigation was obtained. The Department received a complaint regarding staff being rough with residents and speaking inappropriately to residents in care. The complaint also addressed an incident that occurred at the facility involving staff (S3) locking residents out of their bedrooms. Staff members addressed in complaint, S1 and S3, primarily work the day shift in the memory care unit and resident addressed in the complaint, R1, resides in memory care. According to R1’s Physician’s Report LIC602A, R1 is non-ambulatory with a primary diagnosis of Dementia and secondary diagnosis of bipolar disorder. At the time of the incident, the ED was out on leave and there was a temporary ED, Patrick Doppelmayr, in charge of the facility.
******************************************Continued on LIC9099-C***********************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230620103846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GLADDING RIDGE	FACILITY NUMBER: 317000780
	VISIT DATE: 07/07/2023

NARRATIVE

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According to an investigation report provided by the facility, Patrick conducted an investigation regarding an incident that occurred on 6/8/2023 involving S1 and R1. Patrick was informed by a hospice nurse on site checking on another resident that R1 was heard screaming and S1 was heard verbally telling R1 to sit down in a loud voice. When Patrick spoke with S1 to find out what happened, Patrick was informed that R1 has a history of screaming, provoked or not, and that S1 was being hit by R1 when S1 told R1 not to hit them. Patrick suspended S1 while investigating further. Patrick reviewed R1’s file and found past incidents of R1’s habits of screaming. Patrick also conducted interviews with other staff members on shift and there were no issues witnessed. Patrick found no evidence that R1 was being physically abused. S1 was permitted to return to work on 6/12/2023.

Interview conducted by LPA with S1 indicated that, on 6/8/2023, they were assisting R1. S1 stated that they had asked R1 if they were ready to use the restroom and R1 said yes. S1 stated that, while trying to assist R1 with toileting, R1 began to scream. S1 indicated that this is common behavior for R1. S1 stated that a hospice nurse, who was at the facility to care for another resident, came in to see what was happening. S1 stated that they used their walkie talkie to ask for assistance from another caregiver. S1 indicated that they were able to finish helping R1 with toileting needs without assistance from another staff member.

According to interviews conducted with staff (S1, S2, & S3) as well as the ED, R1 has a history of screaming when not provoked. Interviews with S1, S2, S3, and the ED indicated that they have never witnessed staff being rough or aggressive with residents, as well as speaking inappropriately to residents in care. Interviews with S1, S2, and the ED indicated that the only time staff raise their voice when speaking to residents is if the resident is hard of hearing. Interviews with S1, S2, and the ED indicated that the hospice nurse would not know R1’s behaviors as they were providing care for another resident. R1 is not receiving hospice care. Interview with R1 indicated that they like living at the facility, like all the staff members, are treated well, and that staff are very nice. R1 indicated that they have never noticed staff being aggressive, rough, or rude at the facility.

*******************************************Continued on LIC9099-C*********************************************

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230620103846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GLADDING RIDGE	FACILITY NUMBER: 317000780
	VISIT DATE: 07/07/2023

NARRATIVE

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According to interviews with S1, S2, S3, and the ED, residents are able to go into their rooms at all times and resident doors are never locked. Interviews also indicated that most residents keep their doors open. On 6/28/2023, LPA observed many of the residents to have their doors open in the memory care unit. Interview with R1 indicated that they are able to go into their room at all times.

Based on interviews conducted, documentation reviewed, and observation, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited during this visit.

Exit interview conducted. A copy of the report was provided to the ED.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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