525002806-9-8-2026-59-AS-LCRR-DY9TPJ-20260925145426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 525002806
Report Date: 09/08/2026
Date Signed: 09/08/2026 10:14:03 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
08/07/2026 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20260807144304

FACILITY NAME:	GILMORE PLACE		FACILITY NUMBER:	525002806
ADMINISTRATOR:	WILCOX, JULIE		FACILITY TYPE:	740
ADDRESS:	70 GILMORE ROAD		TELEPHONE:	(530) 727-9293
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY:	22	CENSUS:	DATE:	09/08/2026
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Julia Hensel - house manager		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner. - SUNSTANTIATED

INVESTIGATION FINDINGS:

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09/08/2026 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with house manager Julia Hensel. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA conducted interviews and reviewed documents.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

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 4

Control Number 59-AS-20260807144304

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: GILMORE PLACE	FACILITY NUMBER: 525002806
	VISIT DATE: 09/08/2026

NARRATIVE

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Staff did not seek medical attention in a timely manner. - SUNSTANTIATED

It was reported that Resident 1 (R1) had a seizure lasting (30) thirty minutes and staff did not call 911 or take the resident to the hospital.

LPA reviewed the following documents:

MAR for R1 indicates that R1 was away from the facility with family for the dates of 07/31/2026 and 08/01/2026. R1 was not at the facility to receive their medications. The facility reports that they provided R1’s medications to the family for R1 before they left the facility. It is unknown whether R1 took their medication while they were away from the facility.

Incident report details on 08/04/2026 R1 had three seizures which lasted 30 to 45 seconds each and were spaced 5 to 7 minutes apart. Reports that staff offered to call emergency services and R1 declined. No documents related to the 08/04/2026 ER visit were provided to LPA.

Document related to 08/11/2026 follow-up medical appointment reports that R1 was evaluated due to seizure and chest pain. This report includes details that R1 reported to medical staff of a recent episode of multiple seizures back-to-back which included a prolonged 30-minute event. Report states that staff did not call paramedics as expected by R1, which caused R1 concern. Medication levels were checked and reported to be low.

In this report the attending physician reported rapid weight gain of R1 and noted that this may affect the effectiveness of R1’s seizure medication. Seizure protocol instructions in the report include a direction to call 911 if the duration of the seizure lasts more than 5 minutes without signs of stopping or if a second seizure starts immediately after the first without full recovery. According to Healthline, full recovery typically takes anywhere from 5 to 30 minutes after an epileptic seizure.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20260807144304

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: GILMORE PLACE	FACILITY NUMBER: 525002806
	VISIT DATE: 09/08/2026

NARRATIVE

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LPA attempted to contact the staff who assisted R1 during the seizures. LPA did not receive a return call, and therefore no interview was conducted.

Administrator stated It was reported to them that on 08/05/2026 R1 had a seizure. R1 was not transported to the hospital after the seizure. When R1 moved into the facility on 07/30/2025 R1’s physician instructed the facility that EMS should be called if R1 hit their head, had multiple seizures, or the seizure lasted 5 minutes or longer. Administrator stated on 08/05/2026 R1 did have multiple (3 or 4) seizures in the span of 30 minutes but none of them lasted longer than 45 seconds. Administrator stated they did request a seizure plan from R1’s physician when R1 moved in on 07/30/2025 but they had not received it the time of the interview with LPA on 08/12/2026.

It was determined that R1 did have multiple seizures on 08/05/2026 and staff did not call EMS for R1 to be evaluated or transported. At the time of the incident the facility did not have a seizure plan from R1’s doctor with specific instructions. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260807144304

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: GILMORE PLACE	FACILITY NUMBER: 525002806
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/22/2026 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct staff training on when and how to call 911 for a resident who has had a medical emergency.
	8 9 10 11 12 13 14	Based on interviews and document review the facility failed to ensure that EMS was called to evaluate 1 of 20 residents when the resident had multiple seizures. This poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14	Licensee shall submit training materials and staff training sign in sheet to LPA as proof of correction. POC is due 09/22/2026.
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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.

SUPERVISOR'S NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026

LIC9099 (FAS) - (06/04)

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