292700174-5-6-2025-59-AS-KHOS-DGPRX6-20250515132414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 292700174
Report Date: 05/06/2025
Date Signed: 05/06/2025 03:09:39 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
05/05/2025 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20250505093340

FACILITY NAME:	BRUNSWICK VILLAGE		FACILITY NUMBER:	292700174
ADMINISTRATOR:	LAINE, KRISTIE		FACILITY TYPE:	740
ADDRESS:	316 OLYMPIA PARK CIRCLE		TELEPHONE:	(530) 274-1992
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	100	CENSUS: 59	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kristie Laine		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff does not prevent outbreak of scabies.

INVESTIGATION FINDINGS:

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LPA Hiratsuka, conducted the investigation into the allegation above.

LPA reviewed one resident's record and interviewed staff. There is one resident who is being treated for a skin issue for the past several months. The skin issue is not contagious per the doctor who is treating the resident. The resident in question is not required to be quarantined. No residents or staff have come down with any rashes or contagious diseases.

Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

no deficiencies cited

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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