347003712-9-12-2024-59-AS-KHOS-D9DNWQ-20240923104956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:47:24 PM

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
06/18/2024 and conducted by Evaluator Cheyenne Ratajczak

COMPLAINT CONTROL NUMBER: 59-AS-20240618084515

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: 33	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator- Jerilyn Purol		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care

INVESTIGATION FINDINGS:

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On 09/12/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver findings regarding a complaint the Department received on 06/18/24. 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 LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne Ratajczak	TELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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-20240618084515

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: 09/12/2024

NARRATIVE

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Allegation: Resident sustained unexplained bruising while in care
On 06/18/24, around 12:05 AM, a marking was seen on Resident #1 (R1) upper thigh. When R1 was asked about the mark, they could not give any information. Staff #1 (S1), who observed the mark notified Medication Technician and Resident Care Coordinator (RCC). S1 did not know how the mark occurred. Staff #2 (S2) was interviewed, and they stated that they never observed a mark on R1’s upper thigh.

On 06/18/24, around 11:03 AM, Local Law Enforcement arrived at the facility in response to a report of suspected abuse. RCC stated to Local Law Enforcement that the mark was no longer there by 9:00 AM. It was noted that the mark on R1 appeared to be a “pressure mark” due to the time in which it faded. Based on interviews it was noted that R1 has a history of slapping their own thigh at night. Interviews with staff indicated they did not have concerns regarding staff physically abusing residents. Residents interviewed did not express concerns about their safety in the facility.

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 left at the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne Ratajczak	TELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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