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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:13:51 PM

Substantiated


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
02/26/2024 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20240226150013
FACILITY NAME:BROOKDALE SYLVAN RANCHFACILITY NUMBER:
347003712
ADMINISTRATOR:JERILYN PUROLFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 33DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director- Jerilyn PurolTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not dispense resident’s medication(s) as prescribed.
INVESTIGATION FINDINGS:
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On 05/15/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 02/26/24. LPA met with Executive Director (ED) Jerilyn Purol and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews, mediation review and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 6
Control Number 59-AS-20240226150013
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: 05/15/2024
NARRATIVE
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Allegation: Staff did not dispense resident’s medication(s) as prescribed- Substantiated
On 03/28/24 LPA Ratajczak and LPA Mirlohi conducted a medication audit of five (5) residents’ medications. Medication orders were compared to medications being administered and documentation on the Centrally Stored Medication List (LIC622) and Medication Administration Record (MAR) was reviewed. The following discrepancies were noted for three (3) residents, as follows:

Resident #1 (R1)- LPA compared the current medication orders from facility MAR to the medications stored at the facility. LPA observed medication Fluoxetine HCI Oral Capsule 40 mg available to resident however the MAR showed resident missed medications on March 1, 2024 through March 5, 2024. MAR states, “Pharmacy action required” and “other/see nurse notes”. Administrator stated there were no notes documented. LPA observed medication Locaine external patch 4% was available to resident however the MAR showed resident missed medication on March 1, 2024 through March 5, 2024. MAR states, “Pharmacy action required” and “other/see nurse notes”. Administrator stated there were no notes documented. LPA observed medication Lisinopril Oral Tablet 40 mg was available to resident however on the MAR it shows resident missed medication on March 1, 2024 through March 5, 2024. MAR states, “Pharmacy action required” and “other/see nurse notes”. Administrator stated there were no notes documented. LPA observed medication Seroquel tablet 25 mg was available to resident however LPA observed the MAR showed resident received 12 medications however there were only 11 pills popped from the bubble pack. LPA observed medication Montelukast Sodium 10 mg, and observed the bubble pack was started on March 13, 2024. LPA observed there were 4 missing pills from the bubble pack. LPA observed resident PRN medication Hydrocodone-Acetaminophen tablet 5-325 mg was not available to resident. Med Tech stated they will reorder medication today.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 59-AS-20240226150013
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: 05/15/2024
NARRATIVE
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Resident #2 (R2) - LPA compared the current medication orders from facility MAR to the medications stored at the facility. LPA observed resident prescription for Trazodone HCI Oral Tablet 50 mg, with orders stating give 1 tablet by mouth at nighttime for behaviors related to Alzheimer’s disease. LPA reviewed the bubble pack, and observed the bubble pack was started on March 13, 2024. LPA observed there were 18 pills left in the 30-bubble pack which indicated resident missed 1 day of medication. LPA observed resident medication Vitamin D3 tablet 50 MCG to be out and unavailable to resident. Med tech took note and stated they would call and reorder the medication that day. LPA observed medication Seroquel oral tablet 25 mg and observed March 2024 MAR which showed on March 4, 2024 resident did not receive medication and it states under why the medication wasn’t given as “Other/see nurse notes”. Administrator stated there were no notes documented. LPA observed Omeprazole medication available however on the March 2024 MAR it states resident did not received medication on March 1-2 and 4-5, 2024. Reasoning for resident not receiving medication was “pharmacy action required” and “other/see nurse notes”. Administrator stated no notes were documented. LPA observed medication Seroquel was available to resident however the MAR indicates resident did not receive medication on March 4, 2024. It was documented as “other/see nurse notes”, administrator stated notes were not documented.

Resident #3 (R3)- LPA compared the current mediation list to the medications the resident has stored at the facility. R3 was missing the medication Magnesium Hydroxide Oral Suspension 400 MG/5ML. Staff stated that it needs to be reordered and has not been ordered yet.

Based on LPAs medication audit, the facility did not ensure that residents were given their medication as prescribed. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 regulations, Division 6, are being cited on the attached LIC 9099D.

Exit interview conducted a copy of the report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
02/26/2024 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20240226150013

FACILITY NAME:BROOKDALE SYLVAN RANCHFACILITY NUMBER:
347003712
ADMINISTRATOR:JERILYN PUROLFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 33DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director- Jerilyn PurolTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff do not ensure residents are bathed regularly.
Staff did not prevent resident from being hit by another resident.
INVESTIGATION FINDINGS:
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On 05/15/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 02/26/24. LPA met with Executive Director (ED) Jerilyn Purol and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20240226150013
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: 05/15/2024
NARRATIVE
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Staff do not ensure residents are bathed regularly. - Unsubstantiated
During the investigation LPA interviewed staff. Staff interviews indicated that residents are scheduled for showers two (2) to three (3) times a week depending on each resident’s individual care plan. Staff stated that sometimes residents refuse showers, but staff will make several attempts to assist residents with showering if refused. If the resident does not shower at all because of a refusal, staff said that they complete a form indicating a resident has refused showering. During LPA visit, LPA observed the facility to be clean and order free.


Staff did not prevent resident from being hit by another resident.-Unsubstantiated
During the investigation LPA interviewed staff. Staff mentioned that some residents do have diagnosed behavior’s associated with Dementia. Interviews indicated sometimes resident’s will direct behaviors at staff but other times can be directed at other residents. Staff indicated, when staff witness a resident starting to become agitated, they will try to redirect the resident to another activity or different area of the facility. Depending on the type of the behavior a resident has, they will contact the resident’s physician and send the resident out of the community for a re-evaluation. Staff stated that when a resident hits another resident, staff will separate the residents and redirect them to different activities away from one another. Based on staff interviews, staff know which residents tend to have more behaviors and will intervene when they notice that resident is agitated.

Based on this information, these allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.


Exit interview conducted a copy of the report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20240226150013
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

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Licensee will schedule and conduct a training with all med techs, topics to be covered importance of reordering in a timely manner, medication administration, and how to use the MAR. Submit proof of planned training to LPA by POC due date. Once training is complete Licensee will send LPA proof of completed training by all med techs.
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This requirement is not met as evidenced by:
Based on medication audit the facility did not ensure that residents were given their medications as prescribed. This poses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6