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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000960
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:27:19 PM


Document Has Been Signed on 04/02/2024 02:27 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GLORIA'S COUNTRY CAREFACILITY NUMBER:
577000960
ADMINISTRATOR:MONTES, GABRIELFACILITY TYPE:
740
ADDRESS:34606 HIGHWAY 16TELEPHONE:
(530) 668-8444
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:23CENSUS: 16DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maggie Perri, Interim Administrator/Resident Care CoordinatorTIME COMPLETED:
02:27 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an investigation regarding the self-reported incidents of an employee at the facility on 2/17/24-2/18/24 and 2/26/24. LPA met with Maggie Perri (MP), Interim Administrator/Resident Care Coordinator to discuss the incidents.

Incident report 1 stated that S1 reported to work on 2/17/24, clocking in at 10:00 PM. Time clock shows that S1 then clocked out at 12:00 AM. AM staff reported that S1 had failed to complete their duties of chores and resident care during their assigned shift and then vandalized the facility by stopping up the toilets. Morning staff came into the facility at their assigned times and could not find S1 in the building. There was staff on the premises in La Casita, the smaller building housing 4 residents. That staff S3 verifed that S1 was in on the job at 11:30 PM and 4:30 AM. The residents were all safe but staff found incontinent residents wet and untended. S2 said they saw S1's car by the dumpsters out in front of the facility when they arrived at 6:23 AM on 2/18/24, but S1 was not seen anywhere inside. S1's car left shortly after the arrival of morning staff.

Continued on 809-C.....
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GLORIA'S COUNTRY CARE
FACILITY NUMBER: 577000960
VISIT DATE: 04/02/2024
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Continued from 809........

Additionally, Incident report 2 stated S1 came back to the facility on 2/26/24 to collect their final check, as they had not been willing to meet or respond to management's calls and texts during the week prior. S1 texted on 2/26/24 that they would come and pick up check at 11:00 AM and showed up at 2:15 PM, where they picked up check, returned one of the two sets of keys and remarked to MP "why don't we handle this outside?'. LPA conducted interviews and collected documents regarding this incident. No police reports were filed.

No deficiencies or citations were issued at the time of inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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