347003712-9-28-2023-59-AS-KHOS-CW8Q5P-20231002115215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 09/28/2023
Date Signed: 09/28/2023 11:10:25 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230410082316

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:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Executive Director: Jerilyn Purol		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident in care sustained unexplained injuries

INVESTIGATION FINDINGS:

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On 09/28/2023, Licensing Program Analysts (LPAs) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 04/10/2023. 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,admission agreement,identification and emergency information, appraisal, and fall management policy.

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: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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-20230410082316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE SYLVAN RANCH	FACILITY NUMBER: 347003712
	VISIT DATE: 09/28/2023

NARRATIVE

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According to interviews, R1 had multiple abrasions on both knees, toes, right elbow, and right hip. Care staff were not able to recollect falls or how R1 sustained multiple injuries. R1 has history of falls, but no documented falls noted at facility.

The Department reviewed R1's physician's report. Physician's report indicated R1's primary diagnosis is dementia and is confused/disoriented. R1 has visual impairment and has wandering behavior. According to R1's service plan, R1 requires assistance with using the bathroom. R1 uses incontinence products and will remove their depends and urinate on the floor or on bedding. Frequent checks are required throughout the night to ensure that R1's beddings are dry and that R1 has not urinated on the floor. Facility staff is to provide assistance to and from dining room and or community activities as needed due to memory impairment and physical impairment. R1 uses a wheelchair. R1 has fallen in the last twelve months.

The Department interviewed a total of eight (8) facility staff. Interview statements received from six (6) staff indicated, they have observed R1's injuries but have no knowledge of how R1 sustained injuries while in care. Interview statement received from the staff that reported the unwitnessed fall indicated, staff conducted rounds to check on R1 and observed R1 on the floor in the bedroom. Staff assisted R1 into bed and observed a scratch on R1's back. Staff reported the unwitnessed fall to the Med Tech. Med Tech reported the incident to management and R1's responsible party. Interview statement received from ED indicated, staff observed scratches and bruises on R1. The fall may have occurred during the NOC shift and injuries were observed in the morning. There were no signs of trauma. R1 was not sent to the hospital for an evaluation. R1's primary care physician was notified along with R1's RP. A nurse practitioner was at the facility to evaluate R1 and ordered an X-ray on 4/7/2023. Interview statement received from Health and Wellness Director, Ayana Allison, indicated the facility is unsure when the incident occurred. It may have occurred at night on 4/3/2023 or in the morning on 4/4/2023. Management was notified in the morning of 4/4/2023 of the fall incident. The fall is considered unwitnessed due to staff not knowing how R1 fell, the time of the fall, or the date.

R1 did sustained injuries while in care; however, after a thorough investigation, there was no evidence to suggest that the facility was negligent in their care and treatment of 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: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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