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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 08/05/2022
Date Signed: 08/05/2022 01:26:28 PM

Document Has Been Signed on 08/05/2022 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:BROOKDALE SYLVAN RANCHFACILITY NUMBER:
347003712
ADMINISTRATOR:KAYLA YOUNGFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 56CENSUS: 32DATE:
08/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kayla Young, Executive DirectorTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood met with Executive Director (ED), Kayla Young, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 8/4/2022.

On 8/4/2022, the Department received an SIR indicating that, on 7/31/2022, residents R1, R2, R3, R4, R5, and R6 opened a delayed egress gate and left the premises at approximately 9:10 AM. The Fire Department was notified around 9:30 AM that a resident had fallen by an unknown witness. At around 10:00 AM, the fire department notified the facility that they had 4 residents and sent 1 resident to the hospital due to fall. 1 resident was brought back by family due to a tracking device. As of 7/31/2022, all 6 residents had returned back to the facility with no reported injuries.

After incident, facility contacted the fire department on 8/4/2022 to approve locking gates surrounding courtyard area. ED conducted staff training regarding pager system and door alarms on 7/31/2022 and 8/1/2022. ED also conducted staff training regarding engaging all residents on 7/31/2022 and 8/1/2022.

The Department received a Physician’s Report for RCFE (LIC 602) for R1, R2, R3, R4, R5, and R6. A review of all 6 residents’ LIC 602s determined that all 6 residents have a diagnosis of dementia and are unable to leave the facility unassisted.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87705(c)(4) regarding care and supervision of residents with dementia. The deficiency is listed on 809-D.



Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2022 01:26 PM - It Cannot Be Edited


Created By: Michael Hood On 08/05/2022 at 10:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BROOKDALE SYLVAN RANCH
FACILITY NUMBER: 347003712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2022
Section Cited
CCR
87705(c)(4)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Executive Director (ED) conducted staff training regarding pager system, door alarms, and engaging residents on 7/31/2022 and 8/1/2022. ED will conduct a follow-up meeting regarding training to ensure efficient care and supervision. Facility has also approved locked gates with fire department surrounding the courtyard area where incident occurred.
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Based on interviews conducted and records reviewed, the facility did not ensure that residents R1, R2, R3, R4, R5, and R6 were properly supervised, resulting in the AWOL of all 6 residents, which poses an immediate health, safety, and personal rights risk to residents in care.
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Facility will submit proof of training and proof of fire department approval for locked gates by POC due date of 8/6/2022.

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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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
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