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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 04/19/2021
Date Signed: 04/19/2021 05:37:13 PM

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 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: 20DATE:
04/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sharon MonckTIME COMPLETED:
03:20 PM
NARRATIVE
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On (date), Licensing Program Analyst (LPA) Kevin Mknelly spoke toSharon Monck of Brookdale Citrus Heights at approximately 2 PM.
LPA was unable to meet at the facility due to current circumstances.

In addition to the findings for complaint control number 27-AS-20200928100545 which was investigated from 9/29/20 to 4/16 /21, the investigation also found the following violations to have occurred.

On 3/13/21, Wellness Director, Sumit Benipal presented LPA with information that they had failed to report SOC 341- Reports for suspected dependent abuse for many incidents between September 2020 and February 2021 regarding resident to resident altercations. They were reportedly submitted to the Ombudsman but Sumit was not told to report to CCL. 87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by late submission of reports and statement. This posed a potential risk to residents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
VISIT DATE: 04/19/2021
NARRATIVE
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In addition to the failure of facility staff to provide timely assistance with bathing dressing and eating due to staffing shortages, resident’s who required assistance with either incontinence prevention or changing (R1, R2, R6, R12, R16 and R18) were regularly not provided the service agreed to in their care plan.

87625 (b)(3) 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 as evidenced by statements, resident records and staff schedules that a hospice resident will pressure injuries was not kept clean. This posed an immediate risk to this resident. This is a repeat of citation issued on 11/10/20. Civil penalties to be issued.

87405(d) (2) Administrator- Qualifications and Duties (d)(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met by Administrator Jennifer Scarberry as evidenced by failure to provide the necessary support and resources for proper medication management, insure adequate staffing for resident needs, maintain resident records, provide proper reporting of incidents, provide for appropriate staff screening and supervision. This posed an immediate risk to residents.


Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Administrator, ( ) to sign. Administrator to send a signed copy back to CCL.
Additionally, 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: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2021
Section Cited

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87405(d) (2) Administrator- Qualifications and Duties (d)(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met by Administrator Jennifer Scarberry as evidenced by failure to provide the necessary support and resources for proper medication management, insure
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 adequate staffing for resident needs, maintain resident records, provide proper reporting of incidents, provide for appropriate staff screening and supervision. This posed an immediate risk to residents.
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Type A
05/05/2021
Section Cited

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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 as evidenced by statements, resident records and staff schedules that a hospice resident will
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pressure injuries was not kept clean. This posed an immediate risk to this resident. This is a repeat of citation issued on 11/10/20. Civil penalties to be issued.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2021
Section Cited

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Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...
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9
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14
 This requirement was not met as evidenced by late submission of SOC 341 reports and statement. This posed a potential risk to residents.
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9
10
11
12
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14

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2
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7

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4