525002806-3-2-2022-25-AS-KHOS-CCBRUY-20220308122042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 525002806
Report Date: 03/02/2022
Date Signed: 03/02/2022 09:55:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2021 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20211213090224

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:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Julie Wilcox - administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident does not wear adult underwear and urinates on the floor

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

03/02/2022 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Julie Wilcox administrator for the facility. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

It was reported that a resident does not wear adult underwear and urinates on the floor.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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 2

Control Number 25-AS-20211213090224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PLACE	FACILITY NUMBER: 525002806
	VISIT DATE: 03/02/2022

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

During the course of the investigation LPA interviewed 1 administrator, 2 staff, and 2 residents. LPA obtained the following documents to investigate the above allegation: Admissions agreements for 2 residents, physician’s reports for 2 residents, staff list with phone numbers.

Allegation: Resident does not wear adult underwear and urinates on the floor - UNSUBSTANTIATED.

Review of documents revealed that R1 does not suffer from bladder impairment and is able to care for their own toileting needs.

During interview of administrator it was learned that R1 underwent a full hysterectomy in October 2021. Two weeks after surgery R1 developed an infection and suddenly became incontinent. R1 was taken to their physician and treated for the infection. R1 started to wear adult underwear but there were times R1 would take off their adult underwear, would not tell staff that they needed help, and would urinate on the floor of R1’s shared room when R1 stood up. Once the administrator was made aware of this, staff were instructed to ask R1 every hour if R1 needed to change their adult diaper and would provide R1 with assistance when required. R1 experienced the incontinence issues for a total of 2 weeks. After the infection cleared up the incontinence stopped and R1 resumed using the bathroom on their own.

During resident interviews R1 stated that they do wear adult underwear. R2 stated that sometimes R1 does not want to wear adult underwear and has accidents in their room.

During staff interviews two staff stated that R1 had an issue with incontinence for a short time after R1 had emergency surgery but R1 has not had incontinence issues for at least two months.

During LPAs tour of the facility on today’s date, LPA found that the room in question had no urine odor, there is significant staining on the carpet and the licensee has contracted replacement of carpeting in the room with vinyl or laminate flooring.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was emailed to facility administrator Julie Wilcox. No deficiencies were cited on today’s date.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2