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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577000960
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:49:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20230712122208
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:
10/13/2023
UNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Maggie Perri, Resident Care CoordinatorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff forced medication in a resident's mouth.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegation listed above.

LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Maggie Perri, Resident Care Coordinator. The allegation that staff forced medication in a resident’s mouth was investigated. LPA interviewed staff and phone records reporting the incident and determined that the incident did occur.

Continued on 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
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 6
Control Number 21-AS-20230712122208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/13/2023
NARRATIVE
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Continued...

The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20230712122208

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:
10/13/2023
UNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Maggie Perri, Resident Care CoordinatorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff physically abused residents resulting in injury.
Staff over medicated a resident in care.
Staff are giving resident a shower at an unreasonable time.
Staff shoved a soiled diaper in a resident's face.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegations listed above.

The allegation that Staff physically abused residents resulting in injury was investigated. LPA made observations, conducted interviews and reviewed records. LPA found resident R1 had bruising on the back of hands and forearms.


Continued......
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20230712122208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/13/2023
NARRATIVE
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Continued .....

Over the course of the investigation LPA visited the facility 5 times (7/20/23, 08/01/23, 08/17/23, 8/22/23, 8/24/23) and observed R1 picking and pinching at the skin on the back of his hand. Staff and family member corroborated the fact that R1 was causing the self-injury. LPA was unable to determine through interviews and record review that R1’s bruising was caused by staff. There were no other injuries to R1 or other residents observed by LPA or reported to LPA. There was no evidence of physical abuse by staff, therefore the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The allegation that Staff over-medicated a resident (R2) in care was investigated by the Department. Interviews were conducted, care notes, home health, hospice agency and medication records were reviewed. R2 received medication for pain via Hospice. The Department’s investigation determined that the allegation was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The allegation that staff are giving a resident a shower at an unreasonable time was investigated. It was reported that R1 does not like to get up early. It was further reported that R1 is awakened out of his sleep at 4 AM to take a shower. LPA reviewed records and conducted staff interviews. Consultation of the care notes from April through August shows there were many days where R1 was awake and ready for the day when the AM staff arrived to work at 6:30 AM.

Continued......

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20230712122208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/13/2023
NARRATIVE
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There is no record of shower times, however staff said showers were not typically given during early hours unless a resident needed to be cleaned because they became soiled during the overnight hours. There was no proof to determine that the resident was woken up to take showers. The allegation that staff are giving a resident a shower at an unreasonable time is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The allegation that Staff shoved a soiled diaper in a resident’s face was investigated by LPA. Interviews were conducted which did not reveal that this incident occurred. Due to conflicting statements and no evidence that the incident occurred the allegation was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20230712122208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
87465(a)(5)(D)
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87465:Incidental Medical and Dental Care(a)A plan for incidental medical..(5) shall be limited to the following(D)Assistance…. does not include forcing a resident to take….right to refuse medication.
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Administration will re-train staff in the residents rights, including the right of the resident to refuse medications and procedures
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This requirement was not met as evidenced by:
Based on interviews and records, the resident’s right to refuse medication was violated when staff forced resident to take medication by holding resident’s nose to open mouth. This is an immediate risk to the health and safety of resident.

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for reporting and documenting those episodes by 10/16/23.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6