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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005513
Report Date: 12/01/2020
Date Signed: 12/01/2020 01:13:21 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/30/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200330112855
FACILITY NAME:BROOKDALE STERLING COURTFACILITY NUMBER:
317005513
ADMINISTRATOR:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:100 STERLING CTTELEPHONE:
(916) 786-7200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:128CENSUS: 73DATE:
12/01/2020
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Carol DowellTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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- Staff failed to seek timely medical attention for resident while in care.
- Questionable Death.
- Facility failed to meet needs of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Wolter and Keosavang contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 12/01/2020 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 03/30/2020. LPAs spoke with Executive Director (ED) Carol Dowell and explained the purpose of the visit.

Throughout the course of the complaint investigation the department conducted interviews and reviewed documents relevant to the allegations: staff failed to seek timely medical attention for resident while in care, questionable death, and facility failed to meet needs of resident. Documents reviewed revealed that on 01/04/2020 at approximately 6am resident (R1) was found in their bed with visible injuries. According to interviews with staff (S1), they believed that R1 had an unwitnessed fall prior to be checked on, however R1 showed no signs of pain and only had visible injury of a skin tear which S1 bandaged. Staff interviews stated per facility policy it when a resident sustains an unwitnessed fall 9-1-1 is to be called and the resident is to be evaluated and sent to the hospital if needed.

******Continue on LIC 9099-C*******
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
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
Control Number 27-AS-20200330112855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE STERLING COURT
FACILITY NUMBER: 317005513
VISIT DATE: 12/01/2020
NARRATIVE
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S1 stated that a facility nurse (S3) was notified of the incident via text and voicemail as the NOC shift does not have a nurse on shift, and that incoming AM staff (S2) was informed of the incident as well. S2 claimed they were not informed of R1’s incident and that at approximately 7am another staff (S4) requested S2’s help assisting R1 out of bed. R1 was showing signs of pain, and was observed to be unsteady, S2 and S4 transferred R1 into a wheelchair. S2 told the department that a nurse (S5) and the interim ED did evaluate R1 that morning. Interviews with facility nurses revealed that R1 was not assessed the day of the fall by a nurse at the facility, furthermore Interim ED was not present in the facility that day. Documents reviewed revealed R1 was ambulatory and was able to transfer on their own, S2 stated that a wheelchair was used for R1 that day because they were observed to be wobbly when transferring. S2 also indicated R1 was placed in wheelchair to prevent R1 from falling. The department was told in interviews with facility staff that R1 did not normally use a wheelchair, use of the wheelchair indicated R1 was not at their baseline and a change of condition had occurred. Documents reviewed and interviews conducted revealed that at approximately 9am R1 was displaying signs of pain and trying to stand up. S2 told the department during interviews that R1 stated they were in pain but did not say where, S2 was unable to determine where the pain was coming from when evaluating R1. S2 attempted to contact R1’s responsible party (RP) at approximately 9am and was unable to make contact, at approximately 11am the RP was reached and R1 had still not been sent out or evaluated by 9-1-1, RP arrived at the facility at approximately 11:40am, 9-1-1 was called for R1 at approximately 1pm, and R1 was transferred to the hospital where an X-Ray of his pelvis revealed a left femoral (Femur- the long bone that extends from the pelvis to the knee- mayoclinic.org) neck fracture.

The department was told in interviews with facility staff that the facility policy following an unwitnessed fall is to have a nurse evaluate the resident and to contact 9-1-1 for the resident to be sent to the hospital for further evaluation. The facility failed to contact 9-1-1 for R1 on 01/04/2020 after a suspected unwitnessed fall with visible injury despite that being their policy, additionally, R1 was never evaluated by a facility nurse. R1 was discharged to a different facility from the hospital on 01/08/2020 on hospice and passed away on 1/27/2020. Per Death Certificate, cause of death was Cardiopulmonary Arrest with secondary causes -left femoral neck fracture, accidental fall and dementia-etiology unknown.

****** Continue on LIC 9099-C ********

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200330112855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE STERLING COURT
FACILITY NUMBER: 317005513
VISIT DATE: 12/01/2020
NARRATIVE
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CCL reviewed documentation that showed R1 had history of falls on the dates: 3/14/2016, 3/15/2016, 11/24/2017, 12/1/2017, 12/21/2019, 12/25/2019 and ultimately 1/4/2020. On 11/24/2017, R1 was sent to the Emergency Room and 12/1/2017 R1 was evaluated by 9-1-1 for complaints of shoulder pain. R1 had two incidents within a week. On 12/21/2019, 12/25/2019 and 1/4/2020 facility documents show R1 suffered from three unwitnessed falls within eight days. Staff interviews revealed R1 had history of falls, was a fall risk. R1 was placed on Temporary Service Plans (TSP) following the 12/21/2019 and 12/25/2019 falls. TSP indicated that R1 was to be monitored more frequently, every 30 minutes to an hour and to be taken to and from activities in the community. R1’s personal care plan, TSP’s and other documents reviewed all indicated R1 suffered multiple unwitnessed falls with no intervention other than frequent checks of R1 and to assist R1 to activities. R1’s Personal Care Plan, TSP and Based on this information the facility did not meet the needs of R1.

Due to this information CCL finds the allegations 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.

An immediate civil penalty in the amount of $500.00 assessed for R1 sustaining a serious bodily injury while in care at this facility.

As a result of the resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted and a copy of the report will be sent via email to administrator, Carol Dowell, and a signed copy will be returned to LPA.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20200330112855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE STERLING COURT
FACILITY NUMBER: 317005513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2020
Section Cited
HSC
1569.312(e)
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1569.312 Basic Services Reqirements Every facility required to be licensed under this chapter shall provide at least the following basic services:
(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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Licensee agrees to create an individualized fall prevention plan for residents deemed a fall risk going forward, letter of understanding due to CCL by 12/2/2020. Additionally, all staff to be retrained on facility's fall policy by 12/16/2020. Copy of fall policy, training materials, and sign-in sheet due on 12/16/2020 to CCL.
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This requirement was not met as evidenced by: interviews and documentation review. The licensee failed to comply with the regulation cited above. This poses an immediate health and safety risk to residents in care.
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Type A
12/02/2020
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:
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Licensee to hold an in-service training on facility's fall policy including procedure after a resident suffers an unwitnessed fall. Proof of training scheduled due to CCL by 12/2/2020, training to be completed by 12/16/2020 and training materials and sign in sheet to be sent to CCL once completed.
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interviews and documentation review. The licensee failed to comply with the regulation cited above. R1 suffered an injury which was an imminent threat to their health and 9-1-1 was not called immediately. This poses an immediate health and safety 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: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20200330112855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE STERLING COURT
FACILITY NUMBER: 317005513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2020
Section Cited
HSC
1569.269(a)(6)
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 §1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee agrees to hold an in-service training on residents personal rights and observation of the resident to all staff by 12/16/2020. Proof of training scheduled due to CCL by 12/2/2020, training materials and sign in sheet to be sent to CCL by 12/16/2020.
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This requirement was not met as evidenced by: interviews and documentation review. The licensee failed to comply with the regulation cited above. R1 was observed to be not at their baseline by staff on 01/04/2020 and should have been sent out immediately after being observed with injuries from an unwitnessed fall. This poses an immediate health and safety 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: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/30/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200330112855

FACILITY NAME:BROOKDALE STERLING COURTFACILITY NUMBER:
317005513
ADMINISTRATOR:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:100 STERLING CTTELEPHONE:
(916) 786-7200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:128CENSUS: 73DATE:
12/01/2020
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Carol DowellTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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- Facility failed to provide care and supervision resulting in resident sustained a fracture while in care.
- Facility failed to provide care and supervision resulting in resident sustained multiple falls while in care.
- Facility failed to follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Wolter and Keosavang contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 12/01/2020 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 03/30/2020. LPAs spoke with Executive Director (ED) Carol Dowell and explained the purpose of the telephone call.

Throughout the course of the complaint investigation the department conducted interviews and reviewed documents relevant to the allegations: facility failed to provide care and supervision resulting in resident sustaining a fracture while in care, facility failed to provide care and supervision resulting in resident sustaining multiple falls while in care, Insufficient staffing to meet needs of resident, and facility failed to follow reporting requirements. Documents reviewed revealed that the facility had documented six (6) unwitnessed falls for R1 from 2016 to 2020. R1 was deemed a fall risk by the facility in December 2019 after suffering two (2) unwitnessed falls in a short period of time, the first fall occurring 12/21/2019 and the second fall 12/25/2019, both these falls reported no injuries.

***** Continue on LIC 9099-C *****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200330112855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE STERLING COURT
FACILITY NUMBER: 317005513
VISIT DATE: 12/01/2020
NARRATIVE
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Per facility policy once a resident is a deemed a fall risk, they receive more frequent checks, increasing from every 2 hours to every 30 minutes to an hour to ensure safety. Documents also revealed that the family, primary care physician of R1 and CCL were notified of R1’s incidents at the facility. On 01/04/2020, at approximately 6am resident (R1) was found in their bed with visible injuries. According to interviews with staff (S1), they believed that R1 had an unwitnessed fall prior to being checked on, however showed no signs of pain and only had visible injury of a skin tear- which S1 bandaged. S1 also indicated R1 was assessed for injuries. Interviews with facility staff revealed that R1 was checked on per their policy for residents who are deemed falls risks. CCL reviewed staff scheduling documentation and interviewed staff. Documentation and staff interviews showed that the facility maintained the minimum staffing levels in December 2019 and January 2020. CCL reviewed documentation showing alert charting notes and more frequent checks for R1 were made by facility staff.

Due to this information the department finds the allegations to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and copy of report will be sent to facility via email. A signed copy is to be returned to LPA.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7