292700174-1-11-2024-59-AS-KHOS-CZJSXK-20240116131605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 292700174
Report Date: 11/30/2023
Date Signed: 01/11/2024 09:30:22 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, 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
11/09/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20231109113548

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:	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kristie Laine		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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1. Staff do not provide residents with activities while in care
2. Staff do not provide residents with clean linen
3. Staff do not ensure resident rooms are kept clean

INVESTIGATION FINDINGS:

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LPA Hiratsuka, conducted this unannounced complaint visit to deliver the results into the allegations above.

LPA reviewed resident files and conducted interviews with residents and staff. LPA also obtained cleaning schedules and other documentation.

1. LPA observed residents participating in activities during today's visit and on 11/16/2023. LPA also interviewed residents and all but one stated there were are activities. LPA learned the one resident that stated there are none does not chose to participate in activities. LPA observed two separate activity calendars. Allegation unfounded.

2. LPA observed laundry being done during today's visit and on 11/16/2023. LPA interviewed residents and all but one stated their linens get cleaned. Facility has documentation about the one resident refusing service. Allegation unfounded.

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: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 59-AS-20231109113548

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BRUNSWICK VILLAGE	FACILITY NUMBER: 292700174
	VISIT DATE: 11/30/2023

NARRATIVE

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3. LPA obtained the housekeeping schedule and all rooms are cleaned by housekeeping once a week or as needed. Interviews stated all but one resident has their room cleaned. The facility has documentation stating when the one resident allowed staff to clean and not clean their room. LPA inspected twelve rooms and all were clean.

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

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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