317005563-5-28-2025-59-AS-KHOS-DJKMY9-20250714100110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005563
Report Date: 05/28/2025
Date Signed: 05/28/2025 12:54:24 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
07/30/2024 and conducted by Evaluator Todd Tryon

COMPLAINT CONTROL NUMBER: 59-AS-20240730111657

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:	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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Facility staff did not ensure resident was hydrated resulting in hospitalization

INVESTIGATION FINDINGS:

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LPA visited the facility on 5/28/2025 to deliver the findings of the complaint. LPA met with Administrator Cathy Dustin. Regarding allegation that facility staff did not ensure resident was hydrated resulting in hospitalization, through review of documentation it was learned that R1 had a history of urinary tract infections (UTI), and other medical conditions. There is no indication in the records that staff neglected or failed to keep R1
hydrated, fed, or mismanaged R1’s medications. Chart notes indicate staff were routinely offering R1 hydration. It is documented that on 7/24/2024, R1 refused to drink fluids, take medications, and refused to eat meals. Staff noticed the change in condition and contacted hospice and then sent R1 out to the hospital. R1 was hospitalized and diagnosed with failure to thrive.
Therefore, there is no proof that staff were not ensuring resident was hydrated. Allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

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)

Page: 1 of 3

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
07/30/2024 and conducted by Evaluator Todd Tryon

COMPLAINT CONTROL NUMBER: 59-AS-20240730111657

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		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff did not dispense medications as prescribed

INVESTIGATION FINDINGS:

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Regarding the allegation that facility staff did not dispense medications as prescribed, the investigation included a review of resident medication records, interviews with staff and the facility administrator. Based on interviews, staff acknowledged that in the past approximately two years ago that there were isolated instances where pills were found either on the floor or in a resident’s room. However, these incidents were not related to incident alleged in the complaint.
Interviews with the Administrator and staff confirmed that one resident was known to be non-compliant with taking medications and would occasionally spit them out or remove them from their mouth after staff had administered them. This resident behavior likely explains the sporadic discovery of pills.
The Administrator reported that after the issue was raised, she implemented a corrective measure by instructing all staff to observe and confirm that residents had swallowed their medications. Staff interviews confirmed that this new practice has been in place for an extended period and that no further issues with found pills have occurred since the implementation of this measure.

Unsubstantiated

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)

Page: 2 of 3

Control Number 59-AS-20240730111657

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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LPA reviewed current and historical Medication Administration Records (MARs), which showed no documented missed doses or medication errors by staff. Additionally, LPA did not observe any medications left unsecured or unattended during the facility visit.

Based on the information gathered, there is no evidence to support that staff failed to dispense medications as prescribed. Rather, the findings suggest that any instances of medications being found were the result of resident behavior and not a failure on the part of staff to administer medications appropriately. The allegation is UNSUBSTANTIATED, A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the facility staff did not dispense medications as prescribed therefore the allegation is unsubstantiated.

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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