<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005563
Report Date: 07/22/2020
Date Signed: 07/22/2020 12:53:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HAMPSHIRE MANOR INCFACILITY NUMBER:
317005563
ADMINISTRATOR:CATHY DUSTINFACILITY TYPE:
740
ADDRESS:1203 HAMPSHIRE COURTTELEPHONE:
(916) 742-5386
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
07/22/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Cathy Dustin TIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 22, 2020 at 12:00 PM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Executive Director, Cathy Dustin, via telephone to conduct an unannounced Case Management- Incident to obtain additional information regarding an incident that occurred at the facility on 6/25/2020. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an Unusual Incident Report that was submitted to Community Care Licensing (CCL). This report indicates that resident (R1) was sent to the ER due to weakness.

LPA interviewed Cathy regarding the report. The interview with Cathy indicates that R1 was on Hospice. R1 was in the bathroom brushing his teeth with Cathy's assistance. Cathy stated R1 collapsed due to weakness and had fallen backwards and had hit his head on the cabinet. R1 was sent to the ER and had returned to the community. Cathy stated R1 had a full cat scan. Cathy stated R1 had passed away due to his illness which had initially put him on hospice and a Death Report was sent to CCL.

LPA requested for R1's physician report, care plan, discharge medical documents, and death report.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Executive Director, Cathy Dustin, was advised that a signed copy of the report shall be emailed to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1