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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 525002806
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:43:03 PM



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
02/09/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220209165503
FACILITY NAME:GILMORE PLACEFACILITY NUMBER:
525002806
ADMINISTRATOR:WILCOX, JULIEFACILITY TYPE:
740
ADDRESS:70 GILMORE ROADTELEPHONE:
(530) 727-9293
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:22CENSUS: 22DATE:
03/14/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Julie Wilcox - administratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident is left on couch for extended period, not given meals, not having their adult diaper changed.
Staff person locks themselves in the office and tells residents to go away when they ask for assistance.
INVESTIGATION FINDINGS:
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03/14/2022 12:00 PM 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 was left on the couch for an extended period, not given meals, and did not have their adult diaper changed, and a staff person locked themselves in the office and told residents to go away when they asked for assistance.

During the course of the investigation LPA interviewed 1 administrator, 4 staff, and 2 residents. LPA obtained the following documents to investigate the above allegations: Physicians Report for 1 resident, staffing schedules, resident list, staff list with phone numbers, text messages from staff to administrator, written warning from administrator to staff.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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 4
Control Number 25-AS-20220209165503
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: 03/14/2022
NARRATIVE
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Allegation: Resident is left on couch for extended period, not given meals, not having their adult diaper changed. - SUBSTANTIATED.

Review of documents revealed that the administrator issued a written warning to S1 that stated S1 was locked in the office and R1 was left on the couch, had not been fed or changed since S1 arrived on shift. This written warning was signed and acknowledged by S1. A text message that was sent to the administrator on February 5 at 6:25 PM states “S1 is hiding in the office… R1 hasn’t had dinner and has been sitting on the couch the entire day!” A subsequent text message sent from the administrator to S1 on February 5 at 6:32 PM states “It’s time you came out of the office… I don’t think R1 has had dinner or been changed since you got there.” A text message on February 5 at 7:31 PM from the administrator states “Did S1 come out?” to which the reply was “Yeah finally fed her.”

During document review it was learned that R1 has a diagnosis of dementia and requires assistance with personal activities of daily living.

During interview of administrator it was learned that on 2/05/2022 S1 filled in for staff who had called off and worked the evening shift from 4:45 PM - 11:45 PM. The administrator was notified that S1 was hiding in the office and R1 had not been fed. The administrator called S2 and they went to the facility and told S1 that they needed to work. The administrator texted S1 at 6:30 PM and told S1 they better come out of the office, feed R1 and change R1. S1 got R1 up at 6:30 PM and gave R1 dinner. At 7:30 PM administrator received confirmation that, S1 had come out of the office and fed R1. S2 had placed R1 on the couch at about 2:30 PM that day. R1 had lunch and then snack at 2:30 PM. S2 had changed R1's adult diaper at 4:15 PM before they went home and then put R1 back on the couch. S1 changed R1's adult diaper after R1 had dinner at 6:30 PM.

During resident interviews it was learned that on more than one occasion S1 has locked themselves in the office.

Staff interviews confirmed that S1 had left R1 on the couch unattended, did not change R1’s adult diaper and did not feed R1 any meals or snacks during the time period that S1 was locked in the office.

Continued on LIC9099-C

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 25-AS-20220209165503
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: 03/14/2022
NARRATIVE
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Allegation: Staff person locks themselves in the office and tells residents to go away when they ask for assistance. - SUBSTANTIATED.

Review of documents revealed that the administrator issued a written warning to S1 that stated S1 was locked in the office and R1 was left on the couch, had not been fed or changed since S1 arrived on shift. This written warning was signed and acknowledged by S1. A subsequent text message sent from the administrator to S1 on February 5 at 6:32 PM states “It’s time you came out of the office… I don’t think R1 has had dinner or been changed since you got there.”

During interview of administrator it was learned that on 2/05/2022 S1 filled in for staff who had called off and worked the evening shift from 4:45 PM - 11:45 PM, The administrator was notified that S1 was hiding in the office and R1 had not been fed. The administrator texted S1 at 6:30 PM and told S1 they better come out of the office, feed R1 and change R1.

During resident interviews it was learned that on more than one occasion S1 has locked themselves in the office.

Staff interviews confirmed that S1 had locked themselves in the office.

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

Continued on LIC9099D

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20220209165503
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2022
Section Cited
CCR
87625(b)(2)
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87625(b)(2) Managed incontinence – (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by:
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Administrator agrees to conduct an in-service training to all staff on the importance checking on and providing care to residents who require assistance with activities of daily living, in particular incontinence.
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Based on interviews and records review, it was determined that S1 left R1 on the couch without checking if their adult diaper needed to be changed for a significant period of time, which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 3/22/2022.
Type B
03/14/2022
Section Cited
CCR
87468.1(a)
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87468.1(a) Personal Rights of Residents in All Facilities – (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Administrator agrees to conduct an in-service training to all staff on the importance of being focused on providing care and supervision to residents without distractions.
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Based on interviews and records review, it was determined that on 2/05/2022 S1 locked themselves in the facility office and left residents unattended, which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 3/22/2022.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4