525002806-11-12-2024-59-AS-KHOS-DBCKSG-20241125070932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 525002806
Report Date: 11/12/2024
Date Signed: 11/12/2024 10:37:09 AM

Unsubstantiated

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
09/17/2024 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20240917164916

FACILITY NAME:	GILMORE PLACE		FACILITY NUMBER:	525002806
ADMINISTRATOR:	HENSEL, JULIA		FACILITY TYPE:	740
ADDRESS:	70 GILMORE ROAD		TELEPHONE:	(530) 727-9293
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY:	22	CENSUS:	DATE:	11/12/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Julie Wilcox - assistant administrator		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff do not ensure medications are dispensed as prescribed - UNSUBSTANTIATED
Facility is not meeting the incontinence needs of the resident - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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11/12/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with assistant administrator Julie Wilcox. 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 the following documents: Admission agreement, Medication Administration Record (MAR) for the months August and September 2024, Physicians Report, Care Plan, Emergency Room and Wound Care clinic documents for 1 resident.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

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 3

Control Number 59-AS-20240917164916

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: 11/12/2024

NARRATIVE

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Staff do not ensure medications are dispensed as prescribed - UNSUBSTANTIATED

It was reported that Resident 1 (R1) went to the ER and was prescribed an antifungal cream and antibiotics but R1 did not receive their antibiotics until 9/17/24.

LPA reviewed documentation of R1 being seen in the ER on 08/26/2024 to be treated for an abscess. During this visit R1 was prescribed an oral antibiotic to take twice a day for ten days, no antifungal cream was prescribed. Discharge instructions also included a recommendation for follow up appointments for wound care. LPA reviewed documents that show R1 attended wound care appointments on 09/09/2024,09/16/2024, and 09/23/2024. LPA reviewed R1’s Medication Administration Record (MAR) for the months of August and September 2024 which shows that R1 was dispensed their first dose of the oral antibiotic on 08/27/2024 and twice per day for ten days. R1’s MAR does not include an antifungal cream and there is no record of R1 ever being prescribed an antifungal cream.

Administrator stated on 08/26/2024 in the ER they did not prescribe an antifungal cream for R1. They gave R1 an IV antibiotic in the ER, prescribed R1 an oral antibiotic and sent an oral antibiotic home with R1 for the next day. Stated R1 does not use an anti-fungal cream. Stated staff picked up the oral antibiotic on 08/27/2024 and it was dispensed to R1 the same day.

It was determined that R1 was prescribed an oral antibiotic on 08/26/2024, the facility picked up the medication from the pharmacy on 08/27/2024 and dispensed to R1 the same day. R1 has never been prescribed or dispensed an antifungal cream. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240917164916

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: 11/12/2024

NARRATIVE

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Facility is not meeting the incontinence needs of the resident - UNSUBSTANTIATED

It was reported that the ER also requested that R1 wear bigger Depends because the small ones were irritating a fungal infection on their bottom. The RP states it took a week for the facility to receive the order of larger depends.

LPA reviewed R1’s Physicians Report which states that R1 has a diagnosis of urinary incontinence but is able to care for their own toileting needs.

Administrator stated that R1 gets their Depends through their insurance through their doctor and they are delivered once per month. R1 gets 6 packages of 20 each which are placed in R1’s room. R1 is independent and staff don’t have to help R1 with their Depends. R1 wears a size medium. The facility had some size large on hand for R1 to try but R1 complained that they were too large. R1 runs out of Depends every month and the facility purchases extras for the facility and R1 also uses those.

It was determined that R1 is prescribed 6 packages of 20 Depends each month and if R1 runs out the facility provides Depends for R1. There is no mention in the ER discharge documents that R1 has a fungal infection or needs a larger size Depends. This allegation is unsubstantiated.

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

An exit interview was conducted. A copy of the report was provided to assistant administrator Julie Wilcox.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC9099 (FAS) - (06/04)

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