405800467-9-12-2023-29-AS-MJES-CVLR2G-20230912123815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800467
Report Date: 08/08/2023
Date Signed: 09/12/2023 12:39:16 PM

Document Has Been Signed on 09/12/2023 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GARDEN CREEK		FACILITY NUMBER:	405800467
ADMINISTRATOR:	KIRK P KLOTTHOR		FACILITY TYPE:	740
ADDRESS:	73 BROAD STREET		TELEPHONE:	(805) 543-2311
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY: 72		CENSUS: 58	DATE:	08/08/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lisa Hulse / Business Manager		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	Licensing Program Analyst (LPA) Jeffries conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Business Manager Lisa Hulse, and explained the reason for the visit. On 04/19/2023, the Department received a SOC341 Report of Suspected Dependent Adult/Elder Abuse from the facility regarding Resident #1 (R1). The report listed a possible sexual assault of an elderly resident diagnosed with mild cognitive impairment (MCI). On 04/21/2021, the case was referred to the Community Care Licensing Investigations Branch to obtain the police report. On 04/20/2023, at 11:13am, Licensing Program Analyst (LPA) Mark Jeffries contacted the facility Business Office Manager/back up administrator. LPA Jeffries conducted an interview and reviewed the SOC341 report with the Business Office Manager. The SOC341 report revealed that on 04/19/2023 at 12:45pm, Resident #1 (R1) reported to staff that they had been sexually assaulted in their room by a male person. When staff asked R1 when did this happen, R1 stated “about an hour ago (approximately 11:45am)”. The staff reported to the administrator who reported to the San Luis Obispo (SLO) Police Department (PD), Long Term Care Ombudsman (LTCO), Community Care Licensing (CCL) and R1’s resident representative. The SLO PD arrived at approximately 3:00pm and interviewed R1. Per the Business Office Manager, the SLO PD reported that R1 reported that the alleged incident happened at approximately 2:00am and not 11:45am; the male was a gentleman with no description, and R1 consented for sex. The detective interviewed the overnight male staff and R1’s resident representative to determine if there was any misconduct. The resident representative stated that R1 had made a similar accusation four years ago just after a stroke. CONTINUED on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN CREEK	FACILITY NUMBER: 405800467
	VISIT DATE: 08/08/2023

NARRATIVE

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R1 has a diagnosis of MCI and has had no medical issues or medication changes recently. R1 has been a resident for approximately 1 month.

On 04/21/2023, from 8:15am to 10:16am, LPA Jeffries conducted an unannounced health and welfare visit to address the SOC341 report submitted on 04/19/2023, pertaining to Resident #1 (R1). The LPA met with the facility nurse, Jodie Sweeney, LVN and explained the reason for the visit. The LPA conducted a facility tour and observed R1 in the facility. R1 appeared to be in good physical condition and functioning normally in the facility dining room with facility community peers. The LPA requested documents pertinent to the investigation and determined further investigation was required prior to issuing findings.

A review of the SLO PD report revealed that on 04/19/2023 at 11:45am there were no male staff working during the time that R1 reported to staff that the incident occurred. Staff contacted R1’s resident representative who had no concerns and told staff that R1 had reported an almost identical situation four years prior after R1 suffered a stroke. R1 told the officer a conflicting report. R1 stated around 2:00am, R1 was lying on the bed, face down with no underwear on when they heard a man come into the bedroom. There were no lights on and R1 did not see the male. R1 stated the male was a gentleman and asked to have sex. R1 stated they said “yes” giving consent to have sex with R1. R1 stated the sexual encounter lasted about 20 minutes. During that time, R1 did not call out for help or try to fight off the subject. R1 told the officer they were not injured and did not require medical attention. R1 denied ever making a prior claim of sexual assault. R1 denied having any cognitive issues and stated they have not been diagnosed with any cognitive disabilities. The officer informed R1 based on the conflicting statements, they could not substantiate a crime had occurred. The facility informed the officer there was one staff working on the overnight shift and provided the contact information for a statement. In addition, the facility informed the officer no other staff or residents had reported similar sexual related activities associated with the overnight staff.

CONTINUED on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN CREEK	FACILITY NUMBER: 405800467
	VISIT DATE: 08/08/2023

NARRATIVE

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The 06/22/2023, SLO PD supplemental report noted that the officer learned that R1 was having a bowel issue with extreme diarrhea during the time R1 advised the incident occurred which would make it very difficult for the reported incident to occur. The information was provided to the officer by staff of the facility. Based on all the information there did not appear to be any additional follow up that could be completed, and SLO PD was unable to determine or locate any evidence that a crime had occurred therefore, the case was inactivated.

Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation “Resident was sexually assaulted at the facility” is deemed Unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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