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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002694
Report Date: 04/10/2024
Date Signed: 04/10/2024 11:57:40 AM

Substantiated


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
01/16/2024 and conducted by Evaluator Ivan Avila
COMPLAINT CONTROL NUMBER: 59-AS-20240116150521
FACILITY NAME:PRS - BRIDGER HOUSEFACILITY NUMBER:
455002694
ADMINISTRATOR:MCGUIRE, DWIGHTFACILITY TYPE:
735
ADDRESS:3521 BRIDGER DRTELEPHONE:
(530) 921-4077
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 4DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Dwight McGuireTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff are not providing incontinence care to resident in need
Staff are not providing adequate food services to resident
Staff are not treating resident with dignity
Staff neglect resident’s care needs
INVESTIGATION FINDINGS:
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On 04/10/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegations directed by the Department. LPA met with Dwight McGuire and explained the purpose of the visit.

During the investigation process, interviews and a records review were initiated.
LPA investigated the allegation, “Staff are not providing incontinence care to resident in need.” Based on interviews conducted resident was dropped off at Day Program on 1/11/2024 with soiled clothes. Staff at the Day Program took resident into the restroom to clean resident and noticed the pad he was sitting on was turned over which was covered in the resident’s bowel movement. Interviews stated the resident was covered in their bowel movement prior to being dropped off to the Day Program.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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 6
Control Number 59-AS-20240116150521
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: PRS - BRIDGER HOUSE
FACILITY NUMBER: 455002694
VISIT DATE: 04/10/2024
NARRATIVE
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LPA investigated the allegation, “Staff are not providing adequate food services to resident.” Based on interviews conducted and a records review, resident was not given adequate food services during lunch meals. Photographs submitted to LPA showed resident’s meal consisted of two slices of bread and a sprinkle of shredded cheese along with a small orange. Another photograph showed two slices of bread and a cup size of chips. Interviews also stated that the resident had been given a sandwich with a slice of cheese and lettuce on the side as a salad with no dressing.

LPA investigated the allegation, “Staff are not treating resident with dignity. Staff neglect resident’s care needs.” Based on interviews conducted and a records review, resident’s care needs were not met, and resident was not treated with dignity. A video was submitted to LPA that showed staff cutting open the resident’s drinking straw. Staff opened the straw, and it was full of mold. The straw had not been washed or cleaned for some time and mold had been growing inside. Resident had been drinking out of the molded straw due to it not being cleaned properly. One deficiency will be cited as LPA substantiated the same regulation violation.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D.

An exit interview was conducted, and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20240116150521
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: PRS - BRIDGER HOUSE
FACILITY NUMBER: 455002694
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
80072(a)(2)
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80072(a)(2) each client shall have personal rights which include...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidence by:
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Facility will complete a statement of understanding regarding regulation 80072(a)(2). Facility will submit statement of understanding to LPA by POC due date of 04/17/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above as resident was drinking out of a straw filled with mold and which was not cleaned properly, which possesses an immediate Health, Safety, and Personal Rights risk to persons in care.
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Type B
05/01/2024
Section Cited
CCR
80077.4(b)(4)
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80077.4(b)(4) If a licensee accepts or retains a client who has bowel and/or bladder incontinence...(4) Ensuring that clients with incontinence are kept clean and dry, and that the facility remains free of odors. This requirement is not met as evidence by:
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Facility will complete a statement of understanding regarding regulation 80077.4 (b)(4). Facility will submit statement of understanding to LPA by POC due date of 05/01/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above as resident was dropped off at Day Program with soiled clothes, which possesses a potential Health, Safety, and Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20240116150521
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: PRS - BRIDGER HOUSE
FACILITY NUMBER: 455002694
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2024
Section Cited
CCR
80076(a)(1)
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80076(a)(1) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement is not met as evidence by:
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Facility will complete a statement of understanding regarding regulation 80076(a)(1). Facility will submit statement of understanding to LPA by POC due date of 05/01/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above as resident did not receive food of the quality and in the quantity necessary to meet their needs, which possesses a potential Health, Safety, and Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/16/2024 and conducted by Evaluator Ivan Avila
COMPLAINT CONTROL NUMBER: 59-AS-20240116150521

FACILITY NAME:PRS - BRIDGER HOUSEFACILITY NUMBER:
455002694
ADMINISTRATOR:MCGUIRE, DWIGHTFACILITY TYPE:
735
ADDRESS:3521 BRIDGER DRTELEPHONE:
(530) 921-4077
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 4DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Dwight McGuireTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing showers or grooming to resident in need
Staff are not providing laundry services to resident in need
Staff are not providing catheter assistance to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/10/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegations directed by the Department. LPA met with Dwight McGuire and explained the purpose of the visit.

During the investigation process, interviews and a records review were initiated.
LPA investigated the allegation, “Staff are not providing showers or grooming to resident in need.” Based on interviews conducted, staff offer showers to resident throughout the day and week. Resident stated he gets offered showers but sometimes he declines them. When resident asks for a shower, staff assist him in getting one.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20240116150521
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: PRS - BRIDGER HOUSE
FACILITY NUMBER: 455002694
VISIT DATE: 04/10/2024
NARRATIVE
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LPA investigated the allegation, “Staff are not providing laundry services to resident in need.” Based on interviews conducted, resident gets his laundry done a couple times a week. Interviews stated the resident has clean clothes during the day and when he gets visitors.

LPA investigated the allegation, “Staff not providing catheter assistance to resident.” Based on interviews conducted, resident’s catheter gets cleaned each morning and when it leaks. Interviews stated if there is a leak it gets cleaned right away. Staff has cleaned the catheter after the resident accidentally hits it or bumps it into a piece of furniture. Facility has a company that provides assistance in changing the catheter when it needs to be switched.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the report was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6