<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 11/10/2020
Date Signed: 11/16/2020 08:23:42 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/03/2020 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 27-AS-20200603093721
FACILITY NAME:BROOKDALE CITRUS HEIGHTSFACILITY NUMBER:
347003712
ADMINISTRATOR:SCARBERRY, JENNIFERFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 27DATE:
11/10/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jennifer ScarberryTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide identified care and supervision.
Facility staff did not seek timely medical care for resident.
Resident personal rights violated.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/10/20, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Jennifer Scarberry, Administrator of facility Brookdale Citrus Heights – 347003712 at approximately 11:30 AM.
LPA was unable to meet at the facility due to current circumstances.

LPA reviewed client/resident records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Facility staff did not seek timely medical care for resident. On 5/12/20, resident R1 presented with chest pain and SOB at approximately 6:50 PM. Emergency response records show that
9-1-1 was not called until 7:39 PM. Resident was hospitalized until 5/19/20 until discharged and to receive hospice services. Resident was diagnosed with atrial
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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 7
Control Number 27-AS-20200603093721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
VISIT DATE: 11/10/2020
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
fibrillation and sepsis.

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis… This requirement was not met based on statements and records. This posed an immediate risk to the resident.

Facility staff did not provide identified care and supervision. On 5/23/20 a resident, R1, who has dementia and is receiving hospice care, was found unclothed and incontinent when family arrived for a visit. Photographs were taken and submitted to the LPA for this investigation. The facility does not keep detailed records of when incontinent care was provided. The caregiver who was responsible for the resident at that time was no longer employed when an interview was sought. Calls to that employee by LPA were not responded to.

87625 Managed Incontinence (b)…the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met based on statements and photograph. This posed a potential risk to the resident.

Resident personal rights violated. On 5/19/20, R1 was prescribed 10 tablets of a medication for anxiety. R1 was deemed unable to determine his/her own need for a prescription or nonprescription PRN medication and is unable to communicate his/her symptoms clearly by their physician. Instructions were to contact hospice prior to administering this PRN medication. On 5/27/20, R1 was discharge with 3 remaining tabs of the medication. Only one half of one tab out of seven tabs of was recorded as administered to R1 on 5/24/20. The remaining medications administered between 5/21/20 and 5/27/20 were not recorded nor was there record of hospice approval prior to administering this medication to the resident. The need for the medication, the consent of the resident, nor the approval of their physician was recorded.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200603093721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
VISIT DATE: 11/10/2020
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
87468.1(a)(16) Personal Rights of Residents in All Facilities (a) (16) To receive or reject
Medical Care or other services. This requirement was not met based on records and
statements. This posed a potential risk to the resident’s personal rights.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Administrator, Jennifer Scarberry to sign. Administrator to send a signed copy back to CCL.

LPA sent a copy of the appeal rights.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20200603093721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/11/2020
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health ...
1
2
3
4
5
6
7
The immediate response to this incident was address during the course of this investigation.

Licensee will submit proof of training for all medication
8
9
10
11
12
13
14
This requirement was not met based on statements and records. This posed an immediate risk to the resident.

8
9
10
11
12
13
14
 technicians of the duty of care staff to activate 9-1-1 responders when there is an imminent threat to a resident's health or safety by the POC date of 11/24/20.
Request Denied
Type B
11/24/2020
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
Managed Incontinence (b)…the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free
1
2
3
4
5
6
7
The immediate response to this incident was address during the course of this investigation.

Licensee will submit proof of training for all
8
9
10
11
12
13
14
 of odors from incontinence. This requirement was not met based on statements and photograph. This posed a potential risk to the resident.
8
9
10
11
12
13
14
 care staff to the requirements for this restricted health condition, within the last 6 months, by the POC date of 11/24/20.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20200603093721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2020
Section Cited
CCR
87468.1(a)(16)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities (a) (16) To receive or reject Medical Care or other services. This requirement was not met based on records and statements.
1
2
3
4
5
6
7
Licensee will sumbit proof of training for med techs that all PRN medicationprocedures are followed to insure the personal rights of residents by the POC date of 11/24/20.
8
9
10
11
12
13
14

This posed a potential risk to the resident’s personal rights.

8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/03/2020 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 27-AS-20200603093721

FACILITY NAME:BROOKDALE CITRUS HEIGHTSFACILITY NUMBER:
347003712
ADMINISTRATOR:SCARBERRY, JENNIFERFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: DATE:
11/10/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jennifer ScarberryTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has insufficient staff for the needs of residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/10/20, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Jennifer Scarberry, Administrator of facility Brookdale Citrus Heights – 347003712 at approximately 11:30 AM.
LPA was unable to meet at the facility due to current circumstances.

LPA reviewed facility records for May 2020 and conducted extensive interviews. LPA is unable to find and or meet the preponderance, per policy.

Facility has insufficient staff for the needs of residents. Other finding in this complaint identified instances where R1’s needs were not met by caregivers. However, there was not a preponderance of evidence that that was due to insufficient staffing.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200603093721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
VISIT DATE: 11/10/2020
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
finding that the complaint is Unsubstantiated means 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.
As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Administrator, Jennifer Scarberry to sign. Administrator to send a signed copy back to CCL.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7