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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 292700174
Report Date: 07/23/2021
Date Signed: 07/23/2021 02:38:48 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 27-AS-20210129104557
FACILITY NAME:BRUNSWICK VILLAGEFACILITY NUMBER:
292700174
ADMINISTRATOR:LAINE, KRISTIEFACILITY TYPE:
740
ADDRESS:316 OLYMPIA PARK CIRCLETELEPHONE:
(530) 274-1992
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:100CENSUS: 54DATE:
07/23/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kristie Laine; AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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1) Facility did not follow doctor's orders.
2) Facility did not notify POA regarding resident's change of condition.
INVESTIGATION FINDINGS:
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On 7/23/21 at 12:15 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigations visit regarding the above allegations and met with Administrator Kristie Laine. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by facility's automated temperature system and front desk personnel.

Continuation on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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 27-AS-20210129104557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BRUNSWICK VILLAGE
FACILITY NUMBER: 292700174
VISIT DATE: 07/23/2021
NARRATIVE
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1) Facility did not follow doctor's orders.

Based on staff statements and R1's medication documents obtained, LPA determined that the above allegation occurred. R1's centrally stored medication log and narcotics log indicate a completed administration, on 9/30/2020, of the pain medication being question. Facility was unable to produce a discontinue order and confirmed that the medication order was active per the Medication Administration Record (MAR). During this period, R1 was also prescribed an alternate pain medication, which had an active order and was administered, and was recorded as effective on R1's MAR when it was given.

2) Facility did not notify POA regarding resident's change of condition.

Based on statements, R1's incident report dated 11/11/2020, and facility's Fall Response Procedure, LPA determined that the above allegation occurred. R1 had an unwitnessed fall on 11/3/2020 and facility failed to notify responsible party immediately as stated in facility's Fall Response Procedure. R1's responsible party was verbally notified the following day when POA1 came to visit. Facility provided documentation that training was conducted on 11/10/2020 regarding facility's Fall Response Procedures; which includes the facility's reporting requirement.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 27-AS-20210129104557

FACILITY NAME:BRUNSWICK VILLAGEFACILITY NUMBER:
292700174
ADMINISTRATOR:LAINE, KRISTIEFACILITY TYPE:
740
ADDRESS:316 OLYMPIA PARK CIRCLETELEPHONE:
(530) 274-1992
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:100CENSUS: 54DATE:
07/23/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kristie Laine; AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Facility mismanaged resident's medication
INVESTIGATION FINDINGS:
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1) Facility mismanaged resident's medication

Based on documents pharmacy delivery tracking confirmation, facility records, staff personal records, and staff statements obtained, LPA determined the following findings. Pharmacy delivery tracking for R1's medication on 9/10/2020 indicated that S1 received and signed for the medication at 9:55 PM; however, S1's GPS tracking history indicates that S1 was not at the facility at the time and was home by 7:40 PM.

Continuation on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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 27-AS-20210129104557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BRUNSWICK VILLAGE
FACILITY NUMBER: 292700174
VISIT DATE: 07/23/2021
NARRATIVE
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 Pharmacy delivery tracking document for R1's medication on 10/21/2020 states that S2 received the medication and signed for it. A comparison of the handwriting from the pharmacy's delivery service confirmation and S2's handwriting does not match. It is also noted that the name on the pharmacy's delivery service confirmation is spelled incorrectly. LPA is unable to determined if R1's medication were in fact delivered and/or if facility actually received them based on hand writing discrepancy, delivery time, and supporting documents from staff members.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of the report along with appeals rights were given.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210129104557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BRUNSWICK VILLAGE
FACILITY NUMBER: 292700174
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2021
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee agreed to conduct an in service training regarding medication refill procedures and submit training materials along with signed staff participants to LPA by POC date.
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Based on medication records review, Licensee did not maintain 1 of 1 resident's PRN pain medication on order which poses a potential health and safety risk to resident in care.
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Type B
08/02/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by:
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Licensee conducted an in-service training on 11/10/2020 regarding facility's Fall Response Procedure and provided proof to LPA. Deficiency Cleared.
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Based on statements, incident reports, and facility procedures obtained, Licensee notify the responsible party of 1 of 1 resident per facility Fall Response Procedure which poses a potential health and safety risk for resident 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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5