<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002590
Report Date: 09/14/2021
Date Signed: 09/14/2021 10:40:23 AM

Document Has Been Signed on 09/14/2021 10:40 AM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GILMORE RANCH HOMEFACILITY NUMBER:
525002590
ADMINISTRATOR:BURNHAM, CATHERINEFACILITY TYPE:
735
ADDRESS:22030 GILMORE RANCH RDTELEPHONE:
(530) 529-0629
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 0DATE:
09/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:VELVET PETERSONTIME COMPLETED:
10:45 AM
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
Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding three incidents. Met with Velvet Peterson, Administrator.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Staff were contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA Gurriere was screened by staff upon entering the facility.

On 07/08/21 it was reported that a staff person made an error and a resident (Resident 1) missed his morning dose of medications. It was reported that there were no adverse reactions to the missed medication dosage. The incident was discussed with the administrator and it was reported that Resident 1 is doing well. Medication training was provided by an LVN and staff participated.

On 07/26/21 a second medication error was made in that a staff person gave the wrong medications to a resident (Resident 2). The resident was taken to Emergency Services where he was cleared and sent back to the facility. The second incident was discussed with the administrator and it was reported that medication training was provided by Far Northern Regional Center and an LVN. Staff participated in the training.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GILMORE RANCH HOME
FACILITY NUMBER: 525002590
VISIT DATE: 09/14/2021
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
26
27
28
29
30
31
32
If medication errors continue in the future, the administrator is advised that the facility may be cited. An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2