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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 04:30:02 PM

Unfounded


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
03/03/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230303084533
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: 64DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Malissa Acuna, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Centrally stored medications are left unlocked
Facility staff have not completed appropriate training's
Facility is not kept clean
Residents are not provided with proper food service
Staff are smoking in the facility
Staff left nicotine devices accessible to residents in care
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 "centrally stored medications are left unlocked". LPA conducted a facility tour which included 9 resident rooms, medication room, and common living spaces. LPA observed all medications are locked in the medication cart that is locked in the locked medication room. LPA did not observe unlocked medications in resident rooms or common areas. LPA interview facility staff and all staff state that medications are always locked in the medication cart and are not accessible to residents. LPA interview 3 residents in which they stated they have not observed medications unlocked. Continuation on 9099-C.
Unfounded
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 7
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
03/03/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230303084533

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: 64DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Malissa Acuna, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Residents in care do not receive proper medication assistance
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, "Residents in care do not receive proper medication assistance." During today's inspection LPA reviewed 5 resident medications reviewing with facility MAR and medication orders. LPA observed R1 had an order for "Use 1 OneTouch Delica Plus lancet each morning to measure blood sugars". Facility had the diabetic supplies however the order was not on the facility MAR and facility staff have not been providing the testing every morning. In addition, LPA observed R2 had an order for levothyroxine sodium to be given once daily during night shift.
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: 2 of 7
Control Number 59-AS-20230303084533
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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LPA observed on May 3rd through May 8th, medication was not provided to resident due to medication being out of stock at the facility. LPA observed R2 had an order for polyethylene glycol powder as a PRN medication, however medication was not available at the facility. 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: 3 of 7
Control Number 59-AS-20230303084533
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 A
05/18/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed.
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Administrator agrees to complete a training with all staff that dispense medications on proper communication and documentation. Date of training and subject matter
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This requirement is not met as evidenced by: Based on observation, licensee did not provide medications to residents as prescribed which poses an immediate health and safety risk to residents in care.
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to be sent into LPA by 5/18/23.
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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: 4 of 7
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
03/03/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230303084533

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: 64DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Malissa Acuna, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Residents in care do not receive proper incontinence care
Staff did not ensure that resident's hygiene needs were met
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, "Residents in care do not receive proper incontinence care and Staff did not ensure that resident's hygiene needs were met". LPA interviewed care staff in which they stated residents incontience care and hygiene needs were being met. LPA interviewed some staff members in which they stated there has been an issue with NOC shift providing proper incontience care to residents in care. LPA interviewed 3 residents in care that are receiving contience care, and all stated the staff help them with their contience care needs in a timely matter. Due to the conflicting information gathered, LPA finds allegation to be UNSUBSTANTIATED.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.
An exit interview was conducted.
Unsubstantiated
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: 5 of 7
Control Number 59-AS-20230303084533
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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Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, "Facility staff have not completed appropriate training's", LPA reviewed facility staff training records, and observed staff have sufficient training to meet training requirements. LPA interviewed staff in which they stated they have online training and an all-staff training one time a month. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, "Facility is not kept clean". LPA conducted a facility tour which included 9 resident rooms, medication room, and common living spaces in the memory care unit and assisted living side of the facility. LPA observed that the facility was clean, safe and sanitary and odor free. LPA interviewed staff, and all staff stated the housekeepers keep the facility clean and are cleaning daily. LPA interviewed 3 residents in care in which they stated the facility is always clean. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, "Residents are not provided with proper food service". LPA inspected the kitchen and reviewed food menu. LPA observed fresh fruits, vegetables, and other food items. LPA interviewed 3 residents in care in which they stated food is served to them warm and they enjoy the food options. Food is brought into the memory care unit and placed into warming trays in order to keep the food warm. LPA interviewed memory care caregivers in which they stated food is served warm to the residents. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

Continuation on 9099-C.
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: 6 of 7
Control Number 59-AS-20230303084533
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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LPA investigated allegations, "Staff are smoking in the facility and staff left nicotine devices accessible to residents in care". LPA completed a facility tour in which LPA observed two smoking areas outside of the facility. LPA did not observed nicotine devices accessible to residents and LPA did not observe staff smoking in the facility. LPA interviewed staff in which they stated they have not observed staff smoking inside the facility and had not observed nicotine devices in the facility. LPA interviewed 3 residents in care, and all residents stated they have not observed staff smoking in the facility. Due to the information gathered, LPA finds allegation 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.
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: 7 of 7