347003712-11-2-2023-59-AS-KHOS-CXB2HR-20231105162511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 11/02/2023
Date Signed: 11/02/2023 10:41:35 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
04/14/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230414105422

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: 32	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Executive Director: Jerilyn Purol		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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- Facility does not have enough staff to meet the needs of residents in care.
- Facility staff was not adequately trained.
- Staff did not provide all of resident's records to resident's authorized representative.

INVESTIGATION FINDINGS:

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On 11/02/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 04/14/2023. 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, unusual injury/incident report, in-service calendar, SOC 341, personnel report (LIC 500), email communication, and staff trainings.

Continue on page LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 3

Control Number 59-AS-20230414105422

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: 11/02/2023

NARRATIVE

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Allegation: Facility does not have enough staff to meet the needs of residents in care. - Unsubstantiated.
Interview statement received from reporting party indicated, there has been some incidents of R1 being aggressive towards other residents in care. The Facility demanded R1's responsible party (RP) to provide R1 1:1 outside care source. Reporting party stated the facility will continue to provide care but wants outside care source to shadow R1. Outside source is not allowed to interact when R1 gets combative. Reporting party stated does not have any knowledge that the facility had accomplished assisting R1 with activities of daily living (ADLs).

The Department reviewed R1's physician's report. According the R1's physician's report, R1's primary diagnosis is Dementia. R1 has aggressive behavior, wandering behavior, and sundowning behavior. R1 is not able to bathe self and care for own toileting needs. R1 is not able to administer own prescription medications, own PRN medications, and store own medications. According the R1's service plan, showering is provided twice weekly, Wednesday between 9am and 10am, Saturday between 9am and 10 am, along with laundry and housekeeping are subject to change to accommodate R1's schedule. Staff is to remind R1 to change protective undergarments as needed. Staff is to assist R1 approximately every 2 to 4 hours and as needed and to the bathroom brief changes and peri-care is provided at the time of bathroom assistance.
The facility submitted a SOC 341 for review. SOC 341 indicated, R1 kicked R2 in the leg. R1 and R2 were separated and there was no further incident. All parties were notified.

The Department received interview statements from a total of five (5) facility staff. Interview statement received indicated, staff conducted rounds every 2 hours to check on R1. Facility staff assisted R1 with toileting, showers, and medication. Interview statements received from staff indicated, R1 was very combative and aggressive towards staff and residents in care. Staff indicated there were 3 caregivers and 1 Med Tech scheduled for each shift. Staff stated R1's needs were being met.

Allegation: Facility staff was not adequately trained. - Unsubstantiated.
Interview statement received from reporting party indicated staff are not adequately trained to handle residents with Dementia. The Department reviewed the facility's in-service calendar. The facility provides staff training every month. Topics that are discussed during training are behavior intervention, behavior problem-solving, challenging behavior intervention/redirection, and more.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230414105422

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: 11/02/2023

NARRATIVE

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Based on interviews with staff, staff indicated that training was conducted at the time of hire and on a continuous basis per Department regulations. The Department reviewed staff training records and observed that training requirements were met. Staff interviews indicated that staff have required mandated training upon hire and on a continuous basis per facility needs and requirement. Records reviewed indicated that the facility kept proper record of all staff training for all staff without any issues. Though training requirements are met, meaning classes were taken; the Department cannot determine if all staff understood the training and applied it appropriately.

Allegation: Staff did not provide all of resident's records to resident's authorized representative. - Unsubstantiated.

The Department interviewed and received statement from R1's RP. RP indicated RP is working with a Dementia specialist to try to figure out the best medication for R1's behavior. RP requested copies of all incident reports for the last 2 months. The Department interviewed and received statement from Health and Wellness Director (HWD), Ayana Allison. HWD provided the Department with email communicated between RP and HWD for review. HWD indicated incident reports are internal documents only. HWD stated the facility provided RP with 3 options, have the facility fill out a questionnaire, speak to someone regarding the past couple of months or facilitate on-site observation. Interview statement received from ED indicated, the facility's incident reports are not residents' records, this is an internal reporting system tool. ED stated, R1's incident reports also has other residents' in care information.

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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