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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 08/05/2022
Date Signed: 08/05/2022 01:26:28 PM


Document Has Been Signed on 08/05/2022 01:26 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 SYLVAN RANCHFACILITY NUMBER:
347003712
ADMINISTRATOR:KAYLA YOUNGFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 32DATE:
08/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kayla Young, Executive DirectorTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood met with Executive Director (ED), Kayla Young, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 8/4/2022.

On 8/4/2022, the Department received an SIR indicating that, on 7/31/2022, residents R1, R2, R3, R4, R5, and R6 opened a delayed egress gate and left the premises at approximately 9:10 AM. The Fire Department was notified around 9:30 AM that a resident had fallen by an unknown witness. At around 10:00 AM, the fire department notified the facility that they had 4 residents and sent 1 resident to the hospital due to fall. 1 resident was brought back by family due to a tracking device. As of 7/31/2022, all 6 residents had returned back to the facility with no reported injuries.

After incident, facility contacted the fire department on 8/4/2022 to approve locking gates surrounding courtyard area. ED conducted staff training regarding pager system and door alarms on 7/31/2022 and 8/1/2022. ED also conducted staff training regarding engaging all residents on 7/31/2022 and 8/1/2022.

The Department received a Physician’s Report for RCFE (LIC 602) for R1, R2, R3, R4, R5, and R6. A review of all 6 residents’ LIC 602s determined that all 6 residents have a diagnosis of dementia and are unable to leave the facility unassisted.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87705(c)(4) regarding care and supervision of residents with dementia. The deficiency is listed on 809-D.



Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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Document Has Been Signed on 08/05/2022 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SYLVAN RANCH
FACILITY NUMBER: 347003712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2022
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Based on interviews conducted and records reviewed, the facility did not ensure that residents R1, R2, R3, R4, R5, and R6 were properly supervised, resulting in the AWOL of all 6 residents, which poses an immediate health, safety, and personal rights risk to residents in care.
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Facility will submit proof of training and proof of fire department approval for locked gates by POC due date of 8/6/2022.

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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: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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