347003712-4-19-2023-59-AS-APEZ-CRHRGN-20230504130057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 04/19/2023
Date Signed: 04/19/2023 10:10:08 AM

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
02/28/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230228165402

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: 29	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Executive Director: Jerilyn Purol		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff hit resident.

INVESTIGATION FINDINGS:

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On 04/19/2023, Licensing Program Analysts (LPAs) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 02/28/2023. LPA met with Executive Director, Jerilyn Purol, and explained the purpose of the visit.

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, death report, and internal investigation report.

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: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230228165402

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: 04/19/2023

NARRATIVE

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The facility self reported an incident that occurred at the facility and submitted a SOC 341 to the Department for review. According to SOC 341, a total of three facility staff stated they heard staff (S1) admitting to hitting a resident (R1) while assisting R1 in changing. The facility conducted a head to toe assessment on R1 and there were no signs of injuries observed related to the incident. The facility had suspended R1 and conducted an internal investigation which lead to termination.

On 03/07/2023, the Department received interview statements from a total of two out of three staff. Staff (S4) refused to be interviewed. Interview statement received from S2 indicated, S2 overheard S1 admitting to hitting R1 while assisting R1 in changing. S2 stated S2 did not witness S1 hitting R1. Interview statement received from S3 indicated, S3 was present when S1 told two staff that S1 was assisting R1 with changing and R1 did not want S1 to change R1. R1 hit S1 in the face. S2 stated S1 told staff "I just reacted and hit her back." S2 did not observe S1 hit R1, but did go check on R1 after and did not observe bruises and any physical marks on R1. On 04/14/2023, the Department received interview statement from S1. S1 denied hitting R1.

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: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

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