315001843-9-22-2022-25-AS-APEZ-CJMUTF-20220926155149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315001843
Report Date: 09/22/2022
Date Signed: 09/22/2022 11:04:32 AM

Substantiated

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
09/20/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220920164544

FACILITY NAME:	BROOKDALE ROSEVILLE		FACILITY NUMBER:	315001843
ADMINISTRATOR:	CHANTAL S. SALINAS		FACILITY TYPE:	740
ADDRESS:	1 SOMER RIDGE DR		TELEPHONE:	(916) 773-5955
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	40	CENSUS: 18	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Chantal Salinas- Executive Director		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Facility did not answer communications promptly and appropriately to the resident's representatives.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced on 09/22/2022 to commence a complaint investigation. LPA discussed the elements of the allegation with Executive Director, Chantal Salinas. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility.

During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complainit investigation such as, resident roster and authorization for release of records form from the facility.

Continue on page LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

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-20220920164544

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: 09/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/29/2022 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard	1 2 3 4 5 6 7	Executive Director provided resident's records to RP.
	8 9 10 11 12 13 14	for photocopies. This requirement is not met as evidenced by: Based on records review and interviews, R1's records were provided to RP aboout month later from the request date. This poses a potential health, safety, and personal rights violation to residents in care.	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: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220920164544

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: 09/22/2022

NARRATIVE

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According to Brookdale Roseville's authorization for release of records form, resident's (R1) Responsible Party (RP) submitted request on 08/22/2022. On 09/16/2022, RP followed up with ED on the status of the request. Interview statement received from ED, indicated the authorization for release of records form had been misplaced and was found when RP asked for the status of the request. ED stated it took a couple days to get the records together for RP. According to ED, RP picked up R1's records on 09/21/2022 at the facility.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code, Title 22, Division 6, Chapter 3.2 are being cited on the attached LIC9099D.

Appeal rights provided to the facility.

An exit interview was conducted with Chantal Salinas, Executive Director, and a copy of this report will be provided to the facility via email.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

LIC9099 (FAS) - (06/04)

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