317005563-8-22-2024-59-AS-KHOS-D8RQRJ-20240903122401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005563
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:41:13 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2024 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20240702123620

FACILITY NAME:	HAMPSHIRE MANOR INC		FACILITY NUMBER:	317005563
ADMINISTRATOR:	CATHY DUSTIN		FACILITY TYPE:	740
ADDRESS:	1203 HAMPSHIRE COURT		TELEPHONE:	(916) 742-5386
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 6	DATE:	08/22/2024
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Cathy Dustin, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff are not providing incontinence care to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived at the facility unannounced to conduct investigation into allegation listed above. During today’s inspection LPA met with Administrator Cathy Dustin to review the complaint findings.
LPA investigated the allegation, “Facility staff are not providing incontinence care to resident”. During investigation LPA interviewed staff and witnesses and reviewed resident documentation. LPA interviewed administrator in which she stated R1 admitted to the facility independent and ambulatory. R1 then had a fall and started on hospice services. R1 began to decline, and caregivers were having a hard time providing incontinence care to R1. Administrator stated incontinence care was always provided, but recommended R1 move to a higher level of care because they only had 1 caregiver per shift. Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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-20240702123620

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: HAMPSHIRE MANOR INC	FACILITY NUMBER: 317005563
	VISIT DATE: 08/22/2024

NARRATIVE

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Two staff reported that they provided incontinence care to R1 however heard other caregivers were unable to provide incontinence care to R1. Two staff reported R1’s room smelled of urine. LPA interviewed 1 caregiver in which they stated they were able to provide incontinence care to resident and did not observe R1 soiled when they began their shift. LPA interviewed staff from hospice agency in which they stated they had no concerns with R1’s care, never observed R1 soiled, and did not observe a smell in resident room. LPA reviewed R1’s documentation, and staff documented they were performing incontinence care on each shift. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

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