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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 11/10/2020
Date Signed: 11/10/2020 04:01:01 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
06/22/2020 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 27-AS-20200622151756
FACILITY NAME:BROOKDALE CITRUS HEIGHTSFACILITY NUMBER:
347003712
ADMINISTRATOR:SCARBERRY, JENNIFERFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 27DATE:
11/10/2020
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jennifer ScarberryTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff mismanaged resident’s medication.
INVESTIGATION FINDINGS:
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On 11/10/20, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Jennifer Scarberry, Administrator of facility Brookdale Citrus Heights – 347003712 at approximately 11:45 AM.
LPA was unable to meet at the facility due to current circumstances.

LPA reviewed client/resident records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Statements by a staff witness and the Administrator indicate that on or about the “end of May” (Staff could not recall the date and no incident report was submitted.) R1 was given a topical cream, orally, by S1 without a physician’s order to do so and without R1’s consent. Interviews found that S2, med tech, instructed S1 to call them when the resident was ready for the cream. The cream was left unattended on the medication cart. S1 self-
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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 3
Control Number 27-AS-20200622151756
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 CITRUS HEIGHTS
FACILITY NUMBER: 347003712
VISIT DATE: 11/10/2020
NARRATIVE
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initiated administering the cream to R1 without training nor seeking the approval of the med tech. R1 was not injured by the medication error.

87465 (a) (6) (D) Incidental Medical and Dental Care (a) (6) (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement was not met based on records and interviews that three residents (R1, R2, and R3) were given medications which were camouflaged (R2 and R3) or were forced (R1). This posed an immediate risk to residents’ personal rights.

87465 (h) (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met based on records and statements that R1’s cream was accessible to untrained staff and R3’s medication was accessible to R2. This posed an immediate risk to residents’ health and safety.


As a result of this investigation, LPA finds allegation 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. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Exit interview with administrator.
Appeals rights printed.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Administrator, Jennifer Scarberry to sign. Administrator to send a signed copy back to CCL.
Additionally, LPA sent a copy of the appeal rights.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200622151756
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 CITRUS HEIGHTS
FACILITY NUMBER: 347003712
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2020
Section Cited
CCR
87465(a)(6)(D)
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Incidental Medical and Dental Care (a) (6) (D) Assistance... does not include forcing a resident to take medication, hiding or camouflaging medications …, or … infringing upon a resident's right to refuse...
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Both of the staff who were responsible for these errors ceased to be employed at this faciity during the course of this investigation.Licensee will submit a statement of understanding of
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 This requirement was not met based on records and interviews that this violation occurred. This posed an immediate risk to residents’ personal rights.
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this regulation to include that there are measures in place for proper crushing of medications and that only trained med techs are to handle medications. This POC is to be submitted by 11/24/20.
Type B
11/24/2020
Section Cited
CCR
87465(h)(2)
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Incidental Medical and Dental Care. (h) (2) Centrally stored medicines shall be kept in a ... place...not accessible to persons other than employees responsible for... centrally stored medication.
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Licensee will submit a statement of understanding of this regulation
to include that there are measures in place for proper for the safe keeping of medications to be accessible to only
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 This requirement was not met based on records and statements that medication was accessible to others. This posed apotential risk to residents’ health and safety.
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approved employees.
This POC is to be submitted by 11/24/20.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3