405800467-8-9-2023-29-AS-KBUY-CV7K2C-20230830073054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 08/08/2023
Date Signed: 08/09/2023 08:08:49 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20230518172833

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
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Lisa Hulse / Business Manager		TIME COMPLETED:	02:23 PM

ALLEGATION(S):

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Resident was unconscious in the facility bathroom for a long period of time.

INVESTIGATION FINDINGS:

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At 1:00pm on 08/08/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to issue final findings on the allegation above to this complaint. LPA met with Business Manager, Lisa Hulse, announced who he was and the reason for the visit.

As to the allegation of, “Resident was unconscious in the facility bathroom for a long period of time.” It was discovered through interviews and documentation that, on 05/02/2023 Resident 1 (R1) was found unconscious at approximately, 7:45am sitting in their privet restroom. Facility call button record for the date of 05/02/2023 show that R1’s privet bathroom call button was pressed at 4:52am and cleared at 4:54am on 05/02/2023. LPA interviewed Staff 1 (S1) on 08/02/2023, S1 stated that at 4:54am S1 helped R1 back to bed and did not recall anything abnormal care about R1’s visit to their privet restroom at the 4:52 am - 4:54 am resident call for assistance going to and from their privet bathroom. LPA reviewed R1 LIC602 (Physicians Report) dated 01/13/2021, Facilities most recent Resident Assessment for R1, dated 05/06/2022, both reports indicated R1 was ambulatory and independent in all self-care needs. CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230518172833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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LPA reviewed all incident reports from 2022 through May of 2023 and found no incident reports for R1 for any change of condition. LPA conducted staff interviews on 05/19/2023, Staff 2-4 (S2-4) indicated that R1 was ambulatory and had a privet one to one caregiver for companionship during the times of 8am through 9pm daily. Interviews of Residents 1-6 (R1-6) all stated they have never had staff not meet their needs when requested or left unattended when they had needs. R1-6 have had no issues with staff responding to call buttons and all feel very safe at this facility. Based on interviews, and documentation, at this time there is not enough evidence to support the allegation that facility was responsible for, “Resident was unconscious in the facility bathroom for a long period of time.” and is unsubstantiated at this time.

Exit interview, report read, and report provided.

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

LIC9099 (FAS) - (06/04)

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