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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005468
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:06:07 PM

Substantiated


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
10/18/2021 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 25-AS-20211018133106
FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:ANTOINETTE EDWARDSFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: 66DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan WhineryTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Untrained individuals are administering medications to residents.
INVESTIGATION FINDINGS:
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LPA Tryon arrived at the facility unannounced on 4/15/2022 at 11:00 a.m. to continue to work on the complaint. LPA was screened at the door for COVID symptoms, temperature taken. LPA used hand sanitizer and wore a surgical mask. LPA has spoken with both current and former Executive Directors, interviewed staff, interviewed 5 residents, reviewed documentation. Regarding the allegation taht untrained individuals are administering medications to residents, CCL staff has interviewed former ED and staff. LPAs learned that the facility was using temporary staff from agencies quite a bit over the past couple of years. LPA learned that on several occassions the temporary agency staff was asked to pass medications to residents. The former ED stated to CCL staff that she did not verify that the agency staff had done medication training, as the agency does their own training. So, although the agency staff may or may not have had medication training, there is no written documentation to prove it. Therefore, since it cannot be proven, the allegation is SUBSTANTIATED. A finding that the allegation is substantiated means that the preponderance of the evidence standard has been met. The following deficiency is issued as per Title 22 Regulations. Appeal rights provided, exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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 4
Control Number 25-AS-20211018133106
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: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2022
Section Cited
CCR
87411(d)(4)
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All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
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The facility will ensure that all staff responsible for assisting with medications have received appropriate training in safely assisting with self-administered medications.
The Administrator will submit a plan describing how the faciltiy will ensure proper training and documentation in the future.
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Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by: The facility asked Agency staff to assist with medications without documentation that the staff had received appropriate training, posing a potential immediate danger.
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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: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/18/2021 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 25-AS-20211018133106

FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:ANTOINETTE EDWARDSFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan Whinery, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility did not report incidents to licensing as required.
INVESTIGATION FINDINGS:
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LPA has interviewed staff and current and former Executive Directors.
The allegation referred to the occurence of 2 different alleged occurences of residents "eloping" from the facility. In speaking with staff, LPA learned that on both of these occassions, residents did go out the door of the facility, but both times staff were right behind them and accompanied the resident on a "walk" until they were able to encourage the residents to return inside the building. So, although the residents did go through the door, they were accompanied by staff, therefore not an actual elopement. Therefore, although an Incident Report could have been submitted just for information, it appears that the situations never rose to become an actual incident. LPA finds that allegation to be UNFOUNDED.
A finding that an allegation is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
10/18/2021 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 25-AS-20211018133106

FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:ANTOINETTE EDWARDSFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff caused an injury to a resident.
Residents are not receiving medications as needed.
Facility did not maintain adequate staffing to meet the needs of residents.
INVESTIGATION FINDINGS:
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Regarding the allegation that staff caused an injury to a resident, LPA has interviewed staff and reviewed documentation. LPA learned that there was an occassion when resident R1 had some scratches on her arm. In interviewing staff LPA learned that there were apparently marks/scratches/tears on the arm of R1. However, LPA was not able to determine who may have been responsible, as no one witnessed the injury occurring or admitted to anything happening. Therefore the allegation is Unsubstantiated, as there is not adequate evidence to prove anything at this time.
Regarding residents not receiving medications as needed, LPA has reviewed medication orders, MARS, interviewed staff and residents. LPA is not able to ascertain any specific incidents of medications not being received. Therefore, although there may be merit to the allegation, LPA finds no proof at this time. The allegation is Unsubstantiated.
Regarding the facility not maintaining adequate staffing to meet the needs of residents, LPA has interviewed staff and residents. Again, there may be some merit to the allegation, but LPA was not able to learn specific incidents of needs of residents not being met because of staffing. Therefore, the allegation is Unsubtantiated. Exit interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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 4