Gilmore Place

Allegation investigated: Staff did not seek medical attention in a timely manner. - SUNSTANTIATED

/08/2026 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with house manager Julia Hensel. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted interviews and reviewed documents. Continued on LIC9099-C Substantiated Staff did not seek medical attention in a timely manner. - SUNSTANTIATED It was reported that Resident 1 (R1) had a seizure lasting (30) thirty minutes and staff did not call 911 or take the resident to the hospital. LPA reviewed the following documents: MAR for R1 indicates that R1 was away from the facility with family for the dates of 07/31/2026 and 08/01/2026. R1 was not at the facility to receive their medications. The facility reports that they provided R1’s medications to the family for R1 before they left the facility. It is unknown whether R1 took their medication while they were away from the facility. Incident report details on 08/04/2026 R1 had three seizures which lasted 30 to 45 seconds each and were spaced 5 to 7 minutes apart. Reports that staff offered to call emergency services and R1 declined. No documents related to the 08/04/2026 ER visit were provided to LPA. Document related to 08/11/2026 follow-up medical appointment reports that R1 was evaluated due to seizure and chest pain. This report includes details that R1 reported to medical staff of a recent episode of multiple seizures back-to-back which included a prolonged 30-minute event. Report states that staff did not call paramedics as expected by R1, which caused R1 concern. Medication levels were checked and reported to be low. In this report the attending physician reported rapid weight gain of R1 and noted that this may affect the effectiveness of R1’s seizure medication. Seizure protocol instructions in the report include a direction to call 911 if the duration of the seizure lasts more than 5 minutes without signs of stopping or if a second seizure starts immediately after the first without full recovery. According to Healthline, full recovery typically takes anywhere from 5 to 30 minutes after an epileptic seizure. Continued on LIC9099-C LPA attempted to contact the staff who assisted R1 during the seizures. LPA did not receive a return call, and therefore no interview was conducted. Administrator stated It was reported to them that on 08/05/2026 R1 had a seizure. R1 was not transported to the hospital after the seizure. When R1 moved into the facility on 07/30/2025 R1’s physician instructed the facility that EMS should be called if R1 hit their head, had multiple seizures, or the seizure lasted 5 minutes or longer. Administrator stated on 08/05/2026 R1 did have multiple (3 or 4) seizures in the span of 30 minutes but none of them lasted longer than 45 seconds. Administrator stated they did request a seizure plan from R1’s physician when R1 moved in on 07/30/2025 but they had not received it the time of the interview with LPA on 08/12/2026. It was determined that R1 did have multiple seizures on 08/05/2026 and staff did not call EMS for R1 to be evaluated or transported. At the time of the incident the facility did not have a seizure plan from R1’s doctor with specific instructions. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Sep 8, 2026 · control 59-AS-20260807144304

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Sep 22, 2026

87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Based on interviews and document review the facility failed to ensure that EMS was called to evaluate 1 of 20 residents when the resident had multiple seizures. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Licensee agrees to conduct staff training on when and how to call 911 for a resident who has had a medical emergency. Licensee shall submit training materials and staff training sign in sheet to LPA as proof of correction. POC is due 09/22/2026.

Type of visit: Case Management - Other

08/04/2026 01:48 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Julie Wilcox. The purpose of the visit was to check temperatures in the facility. LPA and the administrator toured the facility. LPA took random temperature readings in various common areas and resident rooms. Temperatures ranged between 79 and 84 degrees Fahrenheit. The outside temperature in Red Bluff at the date and time of the visit was 103 degrees. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Case Management - Incident

08/04/2026 112:20 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Julie Wilcox. Today’s visit is regarding an incident that occurred on 07/24/2026. It was reported that on 07/24/2026 at 6:30am Staff 1 (S1) was waking residents up for breakfast and found Resident 1 (R1) in bed unresponsive. S1 notified the house manager and 911 was called immediately. CPR was not performed as R1 had passed away several hours previous which was confirmed by EMS at 06:45 AM. Law enforcement deemed the death as non-suspicious. During the course of the investigation, it was learned that on April 4, 2026 R1 had been hospitalized for a gall bladder infection. R1 was initially treated at a local hospital, subsequently transported to Dignity Health Sacramento, and was then transported to Stanford Hospital for surgery and treatment. R1 was in Stanford Hospital for approximately 2 weeks. On 04/17/2026 R1 came back to the facility with orders for home health. Within 72 hours R1 complained of feeling unwell and was transported back to the local hospital and then back to Stanford Hospital for treatment On 05/01/2026 R1 was admitted to skilled nursing. R1 remained in skilled nursing for 6 weeks to receive IV antibiotic treatments and rehabilitation. R1 was discharged back to the facility from skilled nursing on 07/06/2026 with orders for home health assistance. The skilled nursing facility deemed R1 medically cleared to return to the facility. R1 had seen their primary care physician on 07/15/2026 with an order to start seeing a cardiologist on 07/28/2026 for an echocardiogram and a follow-up appointment was scheduled for 07/29/2026 for a follow-up appointment with their primary care physician. It was determined that the facility made all appropriate arrangement for R1 to seek medical treatment when they initially started feeling unwell and for all subsequent medical appointments prior to the death of R1. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Required - 1 Year

07/14/2026 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Julia Hensel site supervisor and explained the purpose of the visit. Administrator Julie Wilcox and was unavailable for the visit and was notified that LPA would be conducting the inspection. LPA Knight and staff toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to twelve (12) client rooms, common areas, three and one half (3.5) bathrooms, kitchen, storage areas, backyard and office. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. Medication is locked in a cabinet. Cleaning supplies are locked in a cabinet. Common area, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational, are hard wired to the local fire department and serviced by SaFirei Integrated Protection. There are no pools/bodies of water are on premises. The facility has been conducting fire drills monthly. Continued on LIC809-C The following deficiencies were observed during the inspection: LPA observed discarded swamp cooler, wood and various debris on the east side of the exterior of the facility. Licensee agrees to remove the discarded swamp cooler and debris from the East side of the building premises by 07/28/2026. Licensee agrees to send photographs of cleared area to LPA as proof of correction. LPA took temperature readings in common areas and multiple resident rooms. Temperature ranged between 82 and 85 degrees Fahrenheit at 10:00 AM. The temperature in Red Bluff is forecasted to reach 102 degrees Fahrenheit this day and for the next few days. The facility is currently using swamp coolers that are not sufficiently cooling the building. The facility has central air conditioning units but have not been using them. Licensee agrees to utilize the existing central air conditioning in the building or otherwise cool the temperature of common areas and resident rooms. This requirement is due immediately. Deficiencies are being cited under California Code of Regulations, (Title 22) as a result of today’s inspection and are documented on the attached LIC809-D. Exit interview conducted, appeal rights and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2026

Allegation investigated: Staff verbally intimidated resident. - UNSUBSTANTIATED Staff withheld resident’s personal belongings as punishment. - UNSUBSTANTIATED

/12/202611:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Julie Wilcox and explained the purpose of the visit. During the course of the investigation LPA conducted interviews and reviewed documents. Continued on LIC9099-C Unsubstantiated Page 2 Staff verbally intimidated resident. – UNSUBSTANTIATED It was reported that Staff 1 (S1) tried to force Resident 1 (R1) into taking a nebulizer treatment that R1 does not want to take. Also reports that S1 bosses R1 around and tries to “make deals” with R1 so R1 will take the treatment. R1 feels verbally “beat up.” LPA reviewed MAR for October 2025 which includes a prescription for a nebulizer treatment three times per day. The MAR has multiple documented refusal dates by R1 for this medication. R1’s Physician’s Report notes that R1 tends to forget to take their medications and requires assistance with providing medication at the appropriate times. R1 stated they do oxygen at night and don’t need a nebulizer. If R1 refused the treatment some staff would get mad at R1 and some would just say that was not ok. R1 stated staff treat them good at the facility. Staff stated they told R1 that it’s important to take the medication that their doctor prescribed to them, and staff are concerned If R1 won’t take the treatment. Administrator stated that R1 likes to refuse their nebulizer treatment often. Facility staff try to time the treatments and explain to R1 that they really need it and try to re-direct. This allegation is unsubstantiated. Page 3 Staff withheld resident’s personal belongings as punishment. – UNSUBSTANTIATED It was reported S1 withheld cigarettes from R1 because they would not take their nebulizer treatment. R1 stated their doctor wants them to quit smoking. The facility cut R1’s cigarettes back to one per hour when R1 went on oxygen. R1 states they were getting as many as they needed but they tapered them off to one an hour. Staff stated R1 gets one cigarette per hour and R1 forgets that they receive their hourly cigarette. Staff denies withholding cigarettes from R1. Administrator stated staff have not been withholding cigarettes from R1 and the facility has started asking residents to initial every time staff give them a cigarette. This allegation is unsubstantiated. This agency has investigated the above allegations. 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. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Jan 12, 2026 · control 59-AS-20251106090007

Type of visit: Required - 1 Year

07/17/2025 11:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Julie Wilcox and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to twelve (12) client rooms, common areas, three and one half (3.5) bathrooms, kitchen, storage areas, backyard and office. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. Medication was reviewed. Medication is locked in a cabinet. Cleaning supplies are locked in a cabinet. The facility was observed to be at a comfortable temperature. Common area, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational, are hard wired to the local fire department and serviced by Safe Fire Integrated Protection. There are no pools/bodies of water are on premises. The facility conducted an emergency evacuation drill in June 2025 has been conducting fire drills monthly. LPA requested copies of the following documents: LIC500 Personnel Report. In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Jul 17, 2025

Allegation investigated: Staff do not ensure medications are dispensed as prescribed - UNSUBSTANTIATED Facility is not meeting the incontinence needs of the resident - UNSUBSTANTIATED

/12/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with assistant administrator Julie Wilcox. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted interviews and reviewed the following documents: Admission agreement, Medication Administration Record (MAR) for the months August and September 2024, Physicians Report, Care Plan, Emergency Room and Wound Care clinic documents for 1 resident. Continued on LIC9099-C Unsubstantiated Staff do not ensure medications are dispensed as prescribed - UNSUBSTANTIATED It was reported that Resident 1 (R1) went to the ER and was prescribed an antifungal cream and antibiotics but R1 did not receive their antibiotics until 9/17/24. LPA reviewed documentation of R1 being seen in the ER on 08/26/2024 to be treated for an abscess. During this visit R1 was prescribed an oral antibiotic to take twice a day for ten days, no antifungal cream was prescribed. Discharge instructions also included a recommendation for follow up appointments for wound care. LPA reviewed documents that show R1 attended wound care appointments on 09/09/2024,09/16/2024, and 09/23/2024. LPA reviewed R1’s Medication Administration Record (MAR) for the months of August and September 2024 which shows that R1 was dispensed their first dose of the oral antibiotic on 08/27/2024 and twice per day for ten days. R1’s MAR does not include an antifungal cream and there is no record of R1 ever being prescribed an antifungal cream. Administrator stated on 08/26/2024 in the ER they did not prescribe an antifungal cream for R1. They gave R1 an IV antibiotic in the ER, prescribed R1 an oral antibiotic and sent an oral antibiotic home with R1 for the next day. Stated R1 does not use an anti-fungal cream. Stated staff picked up the oral antibiotic on 08/27/2024 and it was dispensed to R1 the same day. It was determined that R1 was prescribed an oral antibiotic on 08/26/2024, the facility picked up the medication from the pharmacy on 08/27/2024 and dispensed to R1 the same day. R1 has never been prescribed or dispensed an antifungal cream. This allegation is unsubstantiated. Continued on LIC9099-C Facility is not meeting the incontinence needs of the resident - UNSUBSTANTIATED It was reported that the ER also requested that R1 wear bigger Depends because the small ones were irritating a fungal infection on their bottom. The RP states it took a week for the facility to receive the order of larger depends. LPA reviewed R1’s Physicians Report which states that R1 has a diagnosis of urinary incontinence but is able to care for their own toileting needs. Administrator stated that R1 gets their Depends through their insurance through their doctor and they are delivered once per month. R1 gets 6 packages of 20 each which are placed in R1’s room. R1 is independent and staff don’t have to help R1 with their Depends. R1 wears a size medium. The facility had some size large on hand for R1 to try but R1 complained that they were too large. R1 runs out of Depends every month and the facility purchases extras for the facility and R1 also uses those. It was determined that R1 is prescribed 6 packages of 20 Depends each month and if R1 runs out the facility provides Depends for R1. There is no mention in the ER discharge documents that R1 has a fungal infection or needs a larger size Depends. This allegation is 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. An exit interview was conducted. A copy of the report was provided to assistant administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 59-AS-20240917164916

Type of visit: Required - 1 Year

07/29/2024 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Julie Wilcox and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to twelve (12) client rooms, common areas, three and one half (3.5) bathrooms, kitchen, storage areas and office. Staff and resident files were reviewed. All employees requiring background checks are cleared. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Medication is locked in a cabinet. Administrator applied for renewal of administrator certificate in April 2024 and will send LPA a copy of their new certificate once received. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in February 2024. Smoke detectors are all operational, are hard wired to the local fire department and serviced by Beacon Fire Alarms & Security Corporation. There are no pools/bodies of water are on premises. The facility has been conducting fire drills monthly. LPA requested copies of the following documents: LIC308 Designation of Facility Responsibility LIC500 Personnel Report In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator Julie Wilcox.the state’s words, verbatim · CDSS document, Jul 29, 2024