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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005563
Report Date: 10/16/2025
Date Signed: 10/16/2025 10:16:17 AM

Substantiated


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
06/12/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250612102414
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: 4DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Administrator - Cathy DustinTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff did not prevent resident from leaving the facility unassisted
INVESTIGATION FINDINGS:
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Licensing Program Analysts Graham Gunby and Bethany Mirlohi arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator, Cathy Dustin. The purpose of the visit was explained, and the complaint investigation findings were discussed.

*Continued on LIC9099-C*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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 3
Control Number 59-AS-20250612102414
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: 10/16/2025
NARRATIVE
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On June 12, 2025, the Department received a complaint alleging that staff did not prevent resident from leaving the facility unassisted resulting in R1 eloping from the facility and requiring hospitalization. The Department reviewed facility records, medical documentation, and staff schedules, and conducted interviews with staff, witnesses, and the Executive Director. The Department also reviewed R1’s physician’s report, care plan, charting notes, and prior incident history regarding wandering and attempted elopement. On June 7, 2025, at approximately 5:20 PM, R1 eloped from the facility without staff’s knowledge. Records confirmed R1 was diagnosed with dementia, required assistance with ADLs, and had a documented history of wandering and exit-seeking behaviors, including prior attempted elopements on 06/30/24, 06/19/24, 06/09/24, 07/12/24, 04/12/25, 04/13/25, and 05/30/25. Caregiver (S1) last observed R1 in the facility at 5:15 PM during shift change. Oncoming caregiver (S2) reported being ill and immediately used the bathroom after arriving on shift, leaving residents unsupervised. While S2 was in the bathroom, R1 exited the facility. Facility charting confirmed R1 was missing from approximately 5:20 PM until approximately 6:20 PM, when R1 was found by a neighbor on their porch. The neighbor called 911. EMS transported R1 to Local Hospital. Medical records confirmed R1 was admitted and treated for urinary tract infection, sepsis, and dehydration, and remained hospitalized until June 10, 2025. Executive Director (S3) acknowledged the facility was aware of R1’s history of wandering but had not updated the care plan to include closer supervision or additional safety measures. Interviews with staff confirmed door alarms were not audible throughout the facility, and no staff were monitoring exits at the time of the incident.

Based on observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met. The facility failed to provide adequate care and supervision to ensure R1’s safety, which resulted in R1 eloping unsupervised for approximately one hour and being hospitalized for sepsis and dehydration. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87463, is being cited on the attached LIC 9099-D. A civil penalty in the amount of $500 is assessed. The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49. Exit interview conducted. Appeal rights provided. Report left with facility Administrator.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250612102414
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/17/2025
Section Cited
CCR
87463(b)(1)(c)
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87463 Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.(1)Significant changes in condition, ..(C)Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This poses an immediate health and safety risk to residents in care.
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Administrator will submit a statement of understanding for section 87463 by 10/17/2025. Administrator will also increase the volume on the alarm system.
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This requirement is not met as evidenced by: Based on record review, the Licensee failed to ensure that R1 has a current reappraisal/Needs and Service Plan on file, which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3