317005563-5-28-2025-59-AS-TORZ-DH56PA-20250528205846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005563
Report Date: 05/28/2025
Date Signed: 05/28/2025 12:49:19 PM

Unfounded

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
08/29/2024 and conducted by Evaluator Todd Tryon

COMPLAINT CONTROL NUMBER: 59-AS-20240829145358

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:	DATE:	05/28/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cathy Dustin, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff spoke to residents in an inappropriate manner.
Staff did not report incidents involving residents as required.
Staff did not seek timely medical attention for resident.
Staff left residents soiled for extended periods.
Licensee does not provide planned activities for residents.
Licensee allowed staff to work prior to obtaining a criminal record clearance.
Licensee did not ensure staff were appropriately trained to provide care to residents

INVESTIGATION FINDINGS:

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LPA Tryon visited the facility on 5/28/2025 to deliver the findings for the complaint. LPA met with Administrator Cathy Dustin.
Over the course of the investigation LPA has interviewed one witness, administrator, six staff, two residents, reviewed documents, toured the facility.
Regarding the allegation that staff spoke to residents in an inappropriate manner, LPA finds that there is no credible evidence that any staff has spoken to residents in an inappropriate manner or in an otherwise disrespectful manner. Allegation is unfounded.
Regarding the allegation that staff did not report incidents involving residents as required, LPA has not found evidence that a particular incident was not reported as required. Allegation is unfounded.
Regarding the allegation that staff did not seek timely medical attention for a resident, it appears that medical assistance has been sought as appropriate. LPA finds no proof that help was unnecessarily delayed in a particular instance. Allegation is unfounded.
Regarding staff leaving residents soiled for extended periods, most staff felt that residents are kept clean

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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-20240829145358

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: HAMPSHIRE MANOR INC	FACILITY NUMBER: 317005563
	VISIT DATE: 05/28/2025

NARRATIVE

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and dry overall. Most staff related that residents are checked/changed at least every 2 hours, more if needed. Some residents may be “heavy wetters” compared to others, but staff do make an effore to keep them clean. Allegation is unfounded.

Regarding the allegation that licensee does not provide planned activities for residents, LPA learned that the facility does have multiple games, activities and so forth that residents can choose. Staff generally related that there are a few residents who enjoy reading, looking at magazines, doing puzzles, exercising/walking. However, it appears that despite activities being offered, residents will generally choose to watch TV, do activities by themselves in their rooms, or visit with each other. The staff cannot force individuals to engage in activities, then can only offer/encourage. LPA finds the allegation to be unfounded.

Regarding Licensee allowing staff to work prior to obtaining a criminal record clearance, current staff have clearance; LPA finds no evidence of staff working without clearance. Allegation is unfounded.

Regarding Licensee not ensuring staff were appropriately trained to provide care to residents, LPA learned that the amount of training given to a particular staff is related to their past experience and abilities. Some staff only need a little training; others need more. Staff receive training through video training, hands-on training, shadowing experienced staff, and in-person training. Allegation is unfounded.

A finding of UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited at this visit. Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

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