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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005468
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:28:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
05/10/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230510141127
FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:MALISSA AUBURNFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: 64DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Malissa Acuna, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Failure to adhere to the admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Malissa Acuna during today's inspection.
LPA investigated allegation, "Failure to adhere to the admission agreement". LPA interviewed relevant party in which they stated R1 and R2 are paying their rent on time every month, however since November 2022 residents continue to receive late payments. Facility has waived the late fees, however the mistake continues to occur. LPA reviewed R1 and R2's admission agreement in which it states, "We will charge a $250.00 late fee if we have not received all fees when due”.

Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 59-AS-20230510141127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE AUBURN
FACILITY NUMBER: 317005468
VISIT DATE: 05/17/2023
NARRATIVE
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Facility continues to charge late payments to R1 and R2 which accorded to the admission agreement should only occur if all fees were not paid on time. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230510141127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE AUBURN
FACILITY NUMBER: 317005468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2023
Section Cited
CCR
87507(f)
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87507(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
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Administrator agrees to submit R1 and R2's billing statement for June which shows issue with billing has been corrected. POC due on 6/3/23.
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This requirement is not met as evidenced by: Based on record review, licensee did not comply with all applicable terms and conditions set forth in the admission agreement which poses a potential risk 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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3