315001843-2-22-2023-25-AS-APEZ-CPGTPZ-20230228135507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315001843
Report Date: 02/22/2023
Date Signed: 02/22/2023 10:15:02 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
02/16/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230216085506

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: 24	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Morgan Whinery- Executive Director		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide all of residents records to resident's authorized representative.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/22/2023, Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced to commence a complaint investigation into allegation listed above. LPA met with Executive Director (ED), Morgan Whinery, and discussed the elements of the allegation. LPA ensured they 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 ED and obtained pertinent documents relevant to the complainit investigation such as, authorization for release of records, affidavit custodian of records, letter of request from law group, and email communications.

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: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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-20230216085506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BROOKDALE ROSEVILLE	FACILITY NUMBER: 315001843
	VISIT DATE: 02/22/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interview statement received from ED indicated, on 01/18/2023 the facility received a letter from Clement Law Group PC requesting for copies of any and all records regarding resident (R1). On 01/23/2023, ED provided copies to management for approval. ED stated requested documents scanned over to management was approved the same day and submitted to the law group. ED provided copies of request and authorization for release of records to LPA for review. Authorization for release of records indicated this request is made pursuant of Health and Safety Code Section 1569.269(a)(21), which provides in part as follows: Residents have the right to prompt access to review all of their records and to purchase photocopies. Photocopies must be provided within two business days at a cost not to exceed the community standards for photocopies.

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 Morgan Whinery, 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: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20230216085506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BROOKDALE ROSEVILLE	FACILITY NUMBER: 315001843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/27/2023 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	ED agrees to review Health and Safety Code section 1569.269 and submit a letter of understanding to CCL by POC due date, 02/27/2023.
	8 9 10 11 12 13 14	for photocopies. This requirement is not met as evidenced by: Based on records review and interviews, On 1/18/23 records were requested. On 1/23/23 R1's records were provided and exceeded two days. 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: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3