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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001843
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:42:09 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
09/28/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220928132255
FACILITY NAME:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:CHANTAL S. SALINASFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 17DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Regional Nurse Robyn MooreTIME COMPLETED:
10:50 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 10/04/2022 to commence a complaint investigation. LPA discussed the elements of the allegation with Reigonal Nurse, Robyn Moore. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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 3
Control Number 25-AS-20220928132255
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: 10/04/2022
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.

On 10/03/2022, Complainant stated Executive Director, Chantal Salinas, did not reach out or provided requested documents. Regional Nurse notified LPA that ED, Chantal Salinas, had left the facility without notice. Regional Nurse stated ED left without notifying staff that authorization for release of records were not completed and provided to R1's RP.

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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20220928132255
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: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
HSC
1569.269(a)(21)
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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
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Regional Nurse agrees to contact Records Manager and provide requested docuemnts. Regional Nurse is provide proof and submit to LPA by POC due date, 10/07/2022.
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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.
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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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3