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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004061
Report Date: 11/07/2024
Date Signed: 11/07/2024 10:04:57 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240905012108
FACILITY NAME:WILLOW CREEK MANORFACILITY NUMBER:
347004061
ADMINISTRATOR:LEPADAT, GABRIELAFACILITY TYPE:
740
ADDRESS:216 WILLOW CREEK DRTELEPHONE:
(916) 984-6918
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Pamela Flemming, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Staff are not following resident's hospice care plan
Staff did not feed resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA spoke to administrator Gabriela Lepadat over the phone and met with caregiver Pamela Flemming during today's inspection.
LPA investigated allegation, “Staff are not following resident's hospice care plan.” During the course of investigation LPA conducted a file review and interviews with staff and witnesses. Relevant Party indicated caregivers were not following hospice care plan by not utilizing hospice equipment and not properly communicating with hospice. LPA interviewed caregivers in which they stated they always followed the hospice care plan. LPA interviewed the hospice nurse in which they stated they had no problems with the care staff, and they staff always listened to hospice instructions. Due to the information gathered, LPA finds allegation to be unfounded.
LPA investigated the allegation, “Staff did not feed resident in a timely manner.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated staff would not feed resident meals in a timely manner which led to him waiting for breakfast until the afternoon.
Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 5
Control Number 59-AS-20240905012108
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: WILLOW CREEK MANOR
FACILITY NUMBER: 347004061
VISIT DATE: 11/07/2024
NARRATIVE
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LPA interviewed caregiver in which she stated resident would normally eat a large breakfast, sleep through lunch, and have a snack and then eat dinner. Depending on the day resident would sleep in and once awake they would offer breakfast. Caregivers had to assist with feeding resident due to resident limitations. LPA interviewed hospice nurse in which they stated there were not issues with staffing feeding resident properly. The nurse stated resident was sleeping more frequently so his mealtimes were frequently different then the normal meal hours. Due the information gathered LPA finds allegation to be UNFOUNDED.

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

Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240905012108

FACILITY NAME:WILLOW CREEK MANORFACILITY NUMBER:
347004061
ADMINISTRATOR:LEPADAT, GABRIELAFACILITY TYPE:
740
ADDRESS:216 WILLOW CREEK DRTELEPHONE:
(916) 984-6918
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Pamela Flemming, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
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9
Staff is not administering medications as prescribed.
Staff handled resident in a rough manner.
Staff left resident in soiled briefs which resulted in an infection.
Staff shaved a resident in care without permission.
Facility violated resident’s personal rights.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA spoke to administrator Gabriela Lepadat over the phone and met with caregiver Pamela Flemming during today's inspection.
LPA investigated allegation, “Staff is not administering medications as prescribed.” LPA conducted a file review and interviews with staff and witnesses. Relevant Party indicated that resident did not get all his medications due to caregivers only providing his medications with alcohol. Caregivers were interviewed and they stated they did not give resident his medications with alcohol. Caregivers stated they only gave medications to resident as prescribed by hospice. LPA interviewed hospice nurse in which he stated he never observed resident receiving his medications with alcohol and he does not remember any medication errors. Due to the conflicting information LPA finds allegation to be UNSUBSTANTIATED.
LPA investigated the allegation, “Staff handled resident in a rough manner”. LPA conducted a file review and interviews with staff and witnesses.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 5
Control Number 59-AS-20240905012108
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: WILLOW CREEK MANOR
FACILITY NUMBER: 347004061
VISIT DATE: 11/07/2024
NARRATIVE
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Relevant Party indicated that caregiver was rough with resident during care. LPA interviewed caregiver in which she stated she was never rough with resident during care. Caregiver stated resident had behaviors of aggression at times, but she was never rough with him. LPA interviewed administrator in which she stated she has never received any complaints or concerns about caregiver being rough and has never witnessed caregiver being rough with any residents. LPA interviewed hospice nurse in which he stated he never observed caregiver being rough or heard of any complaints about caregiver being rough. Hospice nurse stated that resident did have behaviors of aggression, but they were stabilized with the proper medications. Due to the conflicting information gathered, LPA finds allegation to be UNSUBSTANTIATED.

LPA investigated allegation, “Staff left resident in soiled briefs which resulted in an infection.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated resident was left in urine soaked briefs which lead to resident having a fungal infection. LPA interviewed the caregiver in which she stated upon resident being admitted to the facility the staff and hospice groomed resident and cleaned him and found a fungal infection. Hospice nurse was aware and prescribed medications to clear the infection. Caregiver stated resident had behaviors of taking off clothing and briefs but caregivers always cleaned resident and made sure he was dry. LPA interviewed hospice nurse in which they stated caregivers were taking good care of resident and keeping resident clean properly. Nurse stated resident did have a fungal infection they were treating but did not know the cause of the infection. Hospice nurse stated he had no concerns with the care being provided. Due to the information gathered LPA finds the allegation to be UNSUBSTANTIATED.

LPA investigated allegation, “Staff shaved a resident in care without permission.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated that caregiver shaved resident’s eyebrows and mustache off without anyone’s consent. LPA interviewed caregiver in which she stated when resident was admitted into the facility, he was disheveled and needed to be groomed. Caregiver and hospice helped shave and groom him, but they did not shave off his eyebrows. LPA interviewed the hospice nurse in which he stated grooming and shaving resident was on resident hospice care plan. Hospice nurse stated he could not recall if resident’s eyebrows were shaved. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

Continuation on 9099-C.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240905012108
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: WILLOW CREEK MANOR
FACILITY NUMBER: 347004061
VISIT DATE: 11/07/2024
NARRATIVE
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LPA investigated allegation, “Facility violated resident’s personal rights.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated resident was denied phone calls and visitors at the facility. In addition, Relevant party indicated facility was denying resident his mail. LPA interviewed administrator in which she stated resident was never denied visitors, mail, or phone calls. Administrator stated she picks up the facility mail and resident did not receive much mail. LPA interviewed caregiver in which she stated she did not deny resident visitors, calls, or mail. Caregiver stated resident slept a lot during the day so sometimes someone would call the facility phone and the caregiver would report that resident was sleeping and to call back later. Caregiver stated she’d always relay messages to the resident once resident woke up. LPA interviewed the hospice nurse in which he stated he didn’t witness caregivers denying resident phone calls or visitors. Due to the information gathered LPA finds allegation to be 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.

Exit interview was conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5