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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001843
Report Date: 11/16/2021
Date Signed: 11/16/2021 12:05:26 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
09/03/2021 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210903112301
FACILITY NAME:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:SHERRIE KUARFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 20DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Sherrie KuarTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility did not safeguard resident's personal property and did not reimburse resident for lost property.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 11/16/2021 to conduct complaint investigation. LPA met with Executive Director, Sherrie Kuar, and explained the purpose of the visit. 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 and contacted licensee 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. Additionally, LPA were screened by facility staff upon entering the facility.

Throughout the course of complaint investigation, the Department conducted interviews and obtained documents such as LIC 621 client/resident personal property and valuables and copies of check inquiry summary.

***************************************** Continue on page LIC 809-C *************************************************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 8
Control Number 25-AS-20210903112301
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: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 11/16/2021
NARRATIVE
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It was discovered that R1’s hearing aid, fitted sheets, and clothing were missing. The facility was unable to locate the missing items. It was discovered that the facility offered to replace the missing items. According to Executive Director, Business Office Coordinator (BOC) had contacted Corporate to see if a check was delivered to Complainant. At the time of opening the complaint there had been no reimbursement for the items. Since the complaint has been opened, facility has provided reimbursement for $54.80 on 10/14/2021.

Based on interviews conducted and records reviewed, 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 LIC9099D.



Appeal rights provided to the facility.

An exit interview was conducted with Sherrie Kuar, Executive Director, and a copy of this report will be provided to the facility via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20210903112301
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: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables.
(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
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Administrator agrees to review Title 22, Division 6, Chapter 8 Article 04. Operating Requirements 87217 Safeguards for Resident Cash, Personal Property, and Valuables. Administrator agrees to submit written documentation to CCL that regulation was reviewed.
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The licensee shall give the residents receipts for all such articles or cash resources.This requirement is not met as evidenced by: Based on records review and interviews, R1’s hearing aid, fitted sheets, and clothing were missing. This poses a potential health and safety risk to residents 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
09/03/2021 and conducted by Evaluator Sarena Keosavang
COMPLAINT CONTROL NUMBER: 25-AS-20210903112301

FACILITY NAME:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:SHERRIE KUARFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 20DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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- Facility has inadequate record keeping.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 11/16/2021 to conduct complaint investigation. LPA met with Executive Director, Sherrie Kuar, and explained the purpose of the visit. 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 and contacted licensee 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. Additionally, LPA were screened by facility staff upon entering the facility.

Throughout the course of complaint investigation, the Department conducted interviews and obtained documents such as R1’s Physician’s Report, Medication Administration Record (MAR), Personal Service Plan, and Brookdale Roseville’s Progress Notes.

*********************************************** Continue on page LIC 809-C ***********************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20210903112301
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: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 11/16/2021
NARRATIVE
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According to Complainant, concerns about record keeping regarding R1’s stool consistency and constant phone calls because of what Complainant believe to be incomplete record keeping or dishonesty by Med-tech (MT). Complainant stated facility staff (S1) is telling Complainant something believable and Executive Director tells Complainant something completely different as she instructed staff to do.

R1’s Progress Notes revealed that R1 had no bowel movement (BM) on 5/18/2021, 5/19/2021, and 5/20/2021. On 5/21/2021, S1 called R1’s POA and left a voicemail stating R1 has not had a BM for three days. MT 1 called and notified hospice. Hospice stated since R1 does not have any discomfort or pain, the facility will wait until R1’s POA calls back and decides what actions to take. On 5/22/2021, R1’s POA spoke to MT 1 and was notified of R1’s BM and contacted hospice again. According to Executive Director, R1’s medication was causing R1’s no BM. Once R1’s POA and hospice was notified, the facility requested to discontinue the medication. On 5/22/2021 in the evening, R1 was reported to have XL BM.

This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.



An exit interview was conducted with Sherrie Kuar, Executive Director, and a copy of this report will be provided to the facility via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8