317005468-2-18-2021-27-AS-KHOS-BYHPHB-20210223101940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005468
Report Date: 02/18/2021
Date Signed: 02/18/2021 02:50:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200720141157

FACILITY NAME:	BROOKDALE AUBURN		FACILITY NUMBER:	317005468
ADMINISTRATOR:	CHRISTINE SALEE		FACILITY TYPE:	740
ADDRESS:	11550 EDUCATION ST		TELEPHONE:	(530) 888-8847
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	110	CENSUS: 69	DATE:	02/18/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Christine Salee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff failed to follow licensed physician's orders for resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation on 2/18/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the complaint with Christine Salee.

Throughout the course of the investigation, LPA Lusby interviewed Administrator Christine Salee and staff. LPA reviewed R1's physicians report, care plan, medication record, communication between facility and primary physician, and PRN authorization. While the facility was following the medication orders as written by the physician, they were not following the PRN authorization form which stated that any PRN medication requires physician authorization prior to the resident receiving each dose.
Continued on 9099-C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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 3

Control Number 27-AS-20200720141157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE AUBURN	FACILITY NUMBER: 317005468
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/19/2021 Section Cited CCR 87465(d)(1)	1 2 3 4 5 6 7	(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication . . .(1) Facility staff shall contact the resident's physician prior to each dose . . .	1 2 3 4 5 6 7	Facility to submit staff training documentation regarding PRN authorization. Additionally, facility to submit new process in place to ensure staff are referencing PRN
	8 9 10 11 12 13 14	This requirement was not met as evidenced by facility not following PRN authorization form stating that staff must contact physician prior to each PRN prescription medication dose given.	8 9 10 11 12 13 14	authorization prior to dispensing medication
	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: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20200720141157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE AUBURN	FACILITY NUMBER: 317005468
	VISIT DATE: 02/18/2021

NARRATIVE

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As a result of this investigation, the Department finds the allegations to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights were printed and given to Administrator. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

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