<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005468
Report Date: 05/06/2021
Date Signed: 05/12/2021 10:29:31 AM



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
06/29/2020 and conducted by Evaluator Konnor Leitzell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200629162855
FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:CHRISTINE SALEEFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: 72DATE:
05/06/2021
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Christine Salee (Admin)TIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to follow the admission agreement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Konnor Leitzell contacted administrator to deliver the findings for the above allegation “Facility failed to follow the admission agreement”. LPA delivered findings via telephone due to COVID-19 Precautionary Measures. LPA was in contact with Cristine Salee (Admin) to discuss the above allegation and go over the investigation process.

Community Care Licensing (CCL) conducted interviews and reviewed documents throughout the course of the investigation. Through interviews conducted, CCL determined Resident-1’s (R1) care plan was updated by the facility at the request of the DPOA. Due to changes in R1’s care plan, the facility increased R1’s monthly fee. Based on reviewing the Admission Agreement, CCL noted in R1’s Personal Service Plan the language “…the cost of providing the additional personal services (the ‘Personal Service Rate’) will be shared with you.”

Cont. LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
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 5
Control Number 27-AS-20200629162855
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 AUBURN
FACILITY NUMBER: 317005468
VISIT DATE: 05/06/2021
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
The increased cost associated with the new care plan and services being provided with R1 was not discussed with R1’s Durable Power of Attorney (DPOA). CCL learned the DPOA was informed of the changes to R1’s care plan on a telephone call, but did not discuss the change in monthly rate. CCLD determined through documents reviewed and interviews conducted; the increase in Personal Service Rate was not discussed with the DPOA.

Based on the interview and records review, CCL finds the above allegation to be SUBSTANTIATED – A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency is being cited on 9099-D, per Tittle 22 regulations: 87507(f) – Admission Agreements.

Exit interview conducted. Copy of report sent to the facility via e-mail, Administrator to sign and return a copy to CCL either by fax or email, a copy should be retained for facility records as well. Appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200629162855
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 AUBURN
FACILITY NUMBER: 317005468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2021
Section Cited
CCR
87507(f)
1
2
3
4
5
6
7
87507(f)
Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
1
2
3
4
5
6
7
Administrator agrees to provide CCL with a statement of understanding indicating Regulation 87507(f) of CCR has been reviewed and understood. Admin is to include a statement of understanding that the costs associated with changes to a resident's care plan must be reviewed by the resident or RP.
8
9
10
11
12
13
14
This requirement is not met as evidence by facility not ensuring the cost of providing the additional personal services (the ‘Personal Service Rate’) was shared with the DPOA of R1. This poses a potential health and safety risk 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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/29/2020 and conducted by Evaluator Konnor Leitzell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200629162855

FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:CHRISTINE SALEEFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: 72DATE:
05/06/2021
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Christine Salee (Admin)TIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to answer promptly to communications from resident’s representatives.
Facility did not follow reappraisal procedures.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Konnor Leitzell contacted administrator to deliver the findings for the above allegations “Facility failed to answer promptly to communications from resident’s representatives” and “Facility did not follow reappraisal procedures”. LPA delivered findings via telephone due to COVID-19 Precautionary Measures. LPA was in contact with Cristine Salee (Admin) to discuss the above allegations and go over the investigation process.

Based on interviews conducted with the Reporting Party, Administrator, the Health and Wellness Director (HWD), and Deputy Director of Operations, it was discovered that there was a laps in communication between the Facility and DPOA for eight (8) days.

Cont LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200629162855
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 AUBURN
FACILITY NUMBER: 317005468
VISIT DATE: 05/06/2021
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
Based on records reviewed, R1’s Personal Service Plan was received by DPOA on 5/16/2020, the invoice generated for services provided was created on 5/14/2020. CCL learned the new care plan sent to DPOA was returned to the facility with notes and redacted sections the same day indicating DPOA did not agree with the changes made to the care plan. CCL learned DPOA made multiple attempts to reach out to facility to discuss, but was unsuccessful until 5/24/2020, while unapproved care plan was being implemented. As the regulation states “failure to respond to written requests by a family council in a timely manner.”, the use of “timely manner” is found to be ambiguous.

Based on interviews conducted it was discovered that facility performed the reappraisal procedure correctly. The facility involved the POA and reviewed the reappraisal over the phone. The facility went over change of condition, did a Montreal Cognitive Assessment (MOCA), and contacted physician with the new care plan and reappraisal.

Based on the facts provided, LPA finds the above allegations to be to be UNFOUNDED – a finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report sent to the facility via e-mail, Administrator to sign and return a copy to CCL either by fax or email, a copy should be retained for facility records as well.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5