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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005563
Report Date: 07/25/2025
Date Signed: 07/25/2025 02:42:46 PM

Unfounded


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
03/04/2025 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20250304155656
FACILITY NAME:HAMPSHIRE MANOR INCFACILITY NUMBER:
317005563
ADMINISTRATOR:CATHY DUSTINFACILITY TYPE:
740
ADDRESS:1203 HAMPSHIRE COURTTELEPHONE:
(916) 742-5386
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kim Bao Tram Tran, StaffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Residents briefs are not changed often enough/some staff "double-diaper".
Staff do not receive adequate training to care for residents.
Not enough staff to meet resident needs,
Insufficient food supply.
Residents may run out of medications.
Residents may run out of adult briefs/diapers.
INVESTIGATION FINDINGS:
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On 7/25/2025 LPA Tryon went to the facility unannounced to complete the complaint. LPA met with staff Kim Bao Tram Tran and spoke with Cathy Dustin by phone. LPA was able to interview one staff member at the visit. Over the course of the complaint, LPA has interviewed the administrator, four staff, toured the facility including common areas, bedrooms, kitchen, bathrooms, storage areas, and garage.
Regarding resident briefs, staff related that they change residents on a regular basis, and that they are able to keep them pretty clean and dry overall. LPA only heard of one or two "double-diaper" occasions, which were some time ago. This appears to be going smoothly. Allegation is unfounded.
Regarding staff training, all staff interviewed felt that they received plenty of training, and understand their jobs. LPA has reviewed training records. Allegation is unfounded.
Regarding there not being enough staff to meet resident needs, staff generally admitted they are very busy, but that overall the residents' needs are met. Allegation is unfounded.
Regarding insufficient food supply, LPA has toured the house and reviewed food supplies on at least 2 different occassions over a period of months, interviewed staff. There appears to be a good supply of fresh, frozen and dry goods in the house, and the administrator does a good job of procuring supplies. (cont)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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 59-AS-20250304155656
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: HAMPSHIRE MANOR INC
FACILITY NUMBER: 317005563
VISIT DATE: 07/25/2025
NARRATIVE
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Allegation is unfounded,
Regarding the allegation that facility runs out of medications, LPA interviewed staff and viewed medications and logs. There have only been a few occasions when the home came close to running out of a medication. LPA learned that these occasions happened generally when a hospice service was late delivering medications that the facility had already ordered from them. On one occasion the delivery person had quit, and the home had to follow up. However, overall the home does well at ordering/reordering medications timely. Allegation is unfounded.
Regarding the allegation that residents may run out of adult briefs/diapers, LPA has interviewed staff and toured the house. All staff denied running out of briefs. Even if an individual has run short temporarily, the facility has a very large "house supply" of extra briefs and wipes in various sizes and types available, stored in the garage. Therefore, if someone runs out, the supplies are requested from the person responsible for replacing (family members or hospice) there are more than enough extras in the house to cover until a new supply is obtained for the individual. Allegation is unfounded.

A finding of UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2