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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005468
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:03:33 PM


Document Has Been Signed on 06/20/2022 01:03 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: 64DATE:
06/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan Whinery, EDTIME COMPLETED:
01:15 PM
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On 6/20/2022 LPA Tryon visited the facility to follow up on an incident report sent in on 6/14/2022. Prior to the visit LPA had followed self-screening protocol for COVID as per policy, wore a surgical mask, used hand sanitizer, etc. Facility staff then screened LPA at the door, took my temperature, etc. The Incident Report in question stated that on 6/13/2022 a resident (R1) alleged a staff member had grabbed resident's arm in a rough way, and left bruising.

LPA spoke with Executive Director Morgan Whinery. LPA learned that the facility has already thoroughly investigated the incident. The staff in question (S1) admitted to other staff that he did in fact grab resident's arm, when R1 got upset at him, although he said he did not realize he had grabbed it that hard. He also admitted this to his supervisor at the temporary staffing agency. The staffing agency then terminated the employment of S1 with that agency, and he will not be back to work at Brookdale. Brookdale ED had also filed the incident report with CCL, filed a SOC 341 Report of Suspected Abuse with the Ombudsman, filed a report with Placer County Sheriff, and notified resident's POA.

LPA reviewed and obtained copies of documentation related to the incident and investigation.

At this time, it appears that the staff and facility reacted to the report immediately and appropriately and dealt with the situation, reported appropriately, and the staff involved will no longer work at the facility.

No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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