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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005468
Report Date: 08/15/2022
Date Signed: 08/19/2022 02:13:35 PM


Document Has Been Signed on 08/19/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:MORGAN WHINERYFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: DATE:
08/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
12:30 PM
NARRATIVE
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On 8/15/2022 LPA Tryon visited the facility to complete a complaint investigation. During the course of the investigation, Department of Social Services staff also found several other deficiencies related to the complaint that were not stated as allegations.

During investigation, DSS staff learned that several staff had reported to investigators that staff S1 had acted in an inappropriate manner while working with facility residents in that he was witnessed sniffing the crotch of resident's undergarments to determine if the resident needed to be changed, did not wear gloves while providing incontinence care, and was seen sitting or kneeling on the floor close in front of a resident on the toilet while resident was using the toilet. DSS staff found there was no evidence that these incidents were ever reported to appropriate agencies by staff. Therefore, the facility is being issued a deficiency for failure to report.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 AUBURN
FACILITY NUMBER: 317005468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence of any of the
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events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case: Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The facility failed to meet this requirement as evidence by: through staff interview, CCL staff learned that the staff reported that they witnessed another staff caring for a resident in an inapropriate way, and a report was not sent to DSS or other appropriate agencies.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
LIC809 (FAS) - (06/04)
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