347003712-4-5-2023-25-AS-APEZ-CQNUMK-20230407154226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:40:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
02/03/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230203110357

FACILITY NAME:	BROOKDALE SYLVAN RANCH		FACILITY NUMBER:	347003712
ADMINISTRATOR:	JERILYN PUROL		FACILITY TYPE:	740
ADDRESS:	7375 STOCK RANCH RD		TELEPHONE:	(916) 729-2722
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	56	CENSUS: 30	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Jerilyn Purol: Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Wrongful eviction.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/05/2023, Licensing Program Analysts (LPAs) Sarena Keosavang and Sarah Benson arrived at the facility unannounced to deliver final finding Community Care Licensing received on 02/08/2023. LPA met with Executive Director, Jerilyn Purol, and explained the purpose of the visit. LPA ensured the following Personal Protective Equipment (PPE) was worn surgical mask. LPA were screened by facility staff.

During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, service plan, medication list, medication administrator record, and SOC 341.

Continue on page LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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 2

Control Number 25-AS-20230203110357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE SYLVAN RANCH	FACILITY NUMBER: 347003712
	VISIT DATE: 04/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 10/31/2022, R1 was admitted to Brookdale Sylvan Ranch. R1 became aggressive and punched others. On 01/04/2023, R1’s responsible party (RP), ED, and medical staff had a meeting. According to complainant, facility coerced R1 to put in a 30-day notice. On 01/30/2023, R1’s RP sent the facility an email requesting to stop the 30-day notice, but facility is now insisting that R1 be removed from the facility by 02/04/2023. R1’s RP had requested the facility to give R1 until 02/13/2023 to relocate to a different facility. Complainant’s concern is that R1’s RP did not receive a written documentation/notice regarding R1’s eviction and any placement assistance from the facility.

The Department received interview statement from the facility’s ED. ED stated R1’s RP had put in a 30-day notice and last day to move out of the facility is on Saturday, 02/04/2023. ED indicated R1’s RP did not agree on the type of care and had decided to take R1 off of behavior medication. On 02/04/2023, the Ombudsman was present at the facility and had a conversation with ED regarding R1 needing more time to relocate R1 to a different facility. R1’s family is asking for an additional 30 days due to R1's LIC 602 and new diagnosis. ED stated the facility is willing to give R1 more time to relocation until 02/10/2023. However, ED is concerned that R1 and RP may refuse to move out of the facility. LPA explained that R1 has the right to refuse and under no circumstances is the facility allowed to evict resident. The facility may submit a 30-day notice to the Department for approval/denial. The facility decided not to submit a 30-day notice and is working with R1’s RP. On 02/11/2023, R1 had moved out of the facility.

Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted with Executive Director, copy of report was provided via email.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2