292700174-10-15-2021-25-AS-MSEY-C7XQAF-20211019115952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 292700174
Report Date: 10/15/2021
Date Signed: 10/15/2021 12:11:54 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
10/13/2021 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211013154328

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: 53	DATE:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Kristie Laine		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility failed to report outbreak

INVESTIGATION FINDINGS:

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LPA Lusby arrived on Friday October 15, 2021 to conduct a complaint investigation. Prior to 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; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA was screened by staff prior to entry into the facility.

LPA interviewed Administrator Kristie Laine. Kristie acknowledged that between August 27, 2021 and September 13, 2021, two memory care residents and five assisted living residents experienced symptoms of vomiting and/or diarrhea. Additionally, throughout this time frame, 3 staff experienced the same symptoms. Kristie acknowledged that this was not reported to Nevada County Public Health nor Community Care Licensing as an outbreak.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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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Control Number 25-AS-20211013154328

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: 10/15/2021

NARRATIVE

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However, the facility did test all the symptomatic residents to ensure they were not covid positive.

Based on the information gathered through interviews, LPA was able to determine that the facility failed to report a suspected outbreak to Nevada County Public Health and Community Care Licensing. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Please see 9099-D for the deficiency sited during today's visit. Exit interview conducted. A copy of this report and appeal rights were left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211013154328

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: 10/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/29/2021 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	Reporting Requirements Occurrences, such as epidemic outbreaks.. shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.	1 2 3 4 5 6 7	The Administrator agrees to submit a written plan to maintain compliance with this regulation at all times to LPA by POC due date. Plan will include training dates for staff.
	8 9 10 11 12 13 14	This requirement not met as evidence by the facility failing to notify CCL and Nevada County Public Health of 7 residents with similar symptoms as a suspected outbreak.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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