347003712-4-19-2021-27-AS-MSEY-C2FPH2-20210426111911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003712
Report Date: 04/19/2021
Date Signed: 04/19/2021 05:24:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200928100545

FACILITY NAME:	BROOKDALE CITRUS HEIGHTS		FACILITY NUMBER:	347003712
ADMINISTRATOR:	SCARBERRY, JENNIFER		FACILITY TYPE:	740
ADDRESS:	7375 STOCK RANCH RD		TELEPHONE:	(916) 729-2722
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	56	CENSUS: 20	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sharon Monck		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff mismanaging resident’s medication
Resident’s hygienic care needs are not being met
Resident’s records are incomplete
Residents are not being provided activities
Facility is not adequately staffed to meet residents needs

INVESTIGATION FINDINGS:

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On 4/19/21, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Sharon Monck, Operations Specialist and acting Administrator of facility Brookdale Citrus Heights at approximately 2 PM via WebEx. Also present on the call were, Sumit Benipal, Lori Fries and Jina Amstatz.
LPA was unable to meet at the facility due to current circumstances.

LPA reviewed resident records, facility records and conducted extensive interviews. LPA made repeated requests to Administrator, Jennifer Scarberry for facility records which indicate the residents’ acuity based on Brookdale’s assessment formula. LPA Mknelly then requested this calculation as well as a summary of medication errors / refill delays and records for resident falls for July- Sept. 2020. LPA informed Brookdale management, in a Zoom conference call on 3/9/21, that interview reports of regular and frequent falls and medication errors might be disproven by the requested summaries. On 3/17/21, LPA received an email response, from Sharon Monck, that she was advised not to release that generalized data. These findings are based on documents and statements provided.
Based on statements and evidence presented the Department finds that the allegations cited above are substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Regarding the allegation that staff mismanaging resident’s medication, LPA reviewed facility incident reports, staff statements and facility medication records. On 10/9/20, as reported on an LIC 624- Incident report form, R12 did not receive prescribed medication due to lack of refill request by facility staff. R12 was sent to emergency room for medication refill.

In addition to this documented error, staff (S1, S2, S3 and S6) reported in interviews with LPA Mknelly that medication errors such as missed medications, delays in medication refills and delays in medication administration times are regularly occurring. The staff interviewed attributed the errors to under-staffing causing distractions to med techs and inexperienced med techs making errors. LPA was referred by staff to check the facilities medication records and care notes for recording of errors. LPA was also told by S2 and S3 that known errors were not recorded by staff due to lack of time to record and staff attempts to omit their mistake.

One example that bore this out was in March 18, 2021, R6 was mistakenly given R7’s Lorazepam 1 mg tab when R6’s order was for a .5 mg tab. During LPA’s investigation, Lori Fries RN, District Director of Clinical Services, initially stated that there was no known incident in March with these residents. Upon further investigation of facility records and interviewing staff, she found that the internal reporting system was not properly used by staff.

87465 (a)(5) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…by compliance with the following: (5) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evident from records and statements that R12 was not provided medication. This poses an immediate risk to residents in care. This is a repeat violation in 12 months. Civil penalties to be issued.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Regarding the allegation that resident’s hygienic care needs are not being met, LPA reviewed resident records, facility records and staff statements. At the initial investigation visit, on 9/29/20, facility there were 28 residents in care. On 10/19/21 LPA found in records and statements that on 10/17/20 and 10/18/20, only one med tech and one caregiver started each shift with 28 residents in care. On 10/19/20, after 1 overnight caregiver and the med tech left at 6 AM, S2 was the only staff as others did not show up. S2 made calls for assistance. Wellness Director, Sumit Benipal and an LVN from another Brookdale arrived to assist. Resident R21, who is on hospice and is a two person assist, was in heavily soiled depends with a stage three ulcer contaminated. Resident R2, who is a two person assist for behaviors, has been resistant to incontinence care and due to time limits of staff is refusing and not changed regularly.

On 12/25/20, LPA called the facility for a Covid-19 follow-up call and was informed that there were 3 staff working with 21 residents. On 1/10/21, LPA called the facility for a Covid-19 follow-up call and was informed that there were 2 staff working with 21 residents. In a caregiver interview, LPA was informed that on 3/8/21 there were two staff caring for 21 residents on the morning shift.

On 3/13/21, LPA conducted an in-person facility inspection and was informed that there 15 residents with incontinent, nine who require Ambulation assist or cuing for transfers or falls safety, 4 require Dinning Assist, five require two- person assist with transfers and activities of daily living and two are 1:1 for behaviors. On this day, there were two caregivers, a med tech and two additional agency staff for two one-to-one residents present, a house keeping staff, Activities Director and the LVN present at 10 AM in the morning. Care staff and management stated that this is the proper staffing for current residents and their care needs.

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Regarding the allegation that residents are not being provided activities, Interviews found that 87219 Planned Activities (e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, who has the primary responsibility for the organization, conduct and evaluation of planned activities was not present at the facility Sept 2020- March 2021. A new Activities Director has been hired approximated 3/13/21. Staff reported that they were directed to offer resident activities during the activities directors’ vacancy, yet they were often unable to due to the demands of residents’ care and supervision.

Regarding the allegation that facility is not adequately staffed to meet residents’ needs, LPA reviewed facility schedules and timecards and staff statements. In September 2020, there were four resident-to-resident altercations between 9/22/20 and 9/30/20. All occurred in the facility’s common areas and staff were not present when the incident started. On 9/22/20 R10 pushed R1 resulting in R1’s compression fracture. On 9/24/20, R10 pinched R9 resulting in bruising to R9. On 9/27/20, R2 grabbed and would not release R11. Agency staff were present but ineffective. On 9/30/20 R15 and R16 were yelling at each other, throwing food, and grabbing each other. R15 sustained a skin tear. In January and February 2021, there were another 8 such incidents. Wellness Director, Sumit Benipal reported these incidents to LPA Mknelly on 3/13/21 stating they had not been trained to report these incidents to Community Care Licensing (CCL).

R1, on 9/22/20, had a fall with compression. Staff interviewed (S2, S3 and S9) stated R1 was known to reach over others for food and R10 stated that they had pushed her away when she reached over him. Staff were not present in the area though both residents were known to have these behaviors.
LPA had been told by Administrator Jennifer Scarberry, on 9/29/20, that agency staff are utilized primarily as “floater” support for staffing shortages due to the special needs of residents. However, staff reported that agency staff have been discontinued do to cost. LPA review of records found that many staff shortages were not filled by agency staff. LPA also conducted extensive Covid -19 outbreak contacts where staff shortages were explicitly inquired about and denied by the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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10/19/20 LPA found in records and statements that on 10/17/20 and 10/18/20, a med tech and a caregiver started each shift with 28 residents in care. On 10/19/20, after 1 overnight caregiver and the med tech left at 6 AM, S2 was the only staff as others did not show up. S2 made calls for assistance. Wellness Director, Sumit Benipal and an LVN from another Brookdale arrived to assist. Resident R21, who is on hospice and is a two person assist, was in heavily soiled depends with a stage three ulcer contaminated. Resident R2, who is a two person assist for behaviors, has been resistant to incontinence care and due to time limits of staff is refusing and not changed regularly.

On 12/25/20, LPA called the facility for a Covid-19 follow-up call and was informed that there were 3 staff working with 21 residents.

On 1/10/21, LPA called the facility for a Covid-19 follow-up call and was informed that there were 2 staff working with 21 residents.

S1, S2, S3, S4, S5, S6 and S9 stated during interviews that during the period of Aug-Sept of 2020, and continuing up to 3/8/21, staffing was often not sufficient to meet the needs of the residents. Reported in interviews by staff, when there were days with one caregiver assigned to 10-13 residents with incontinence waited to be changed when soiled, residents with ambulation assistance needs would not always wait for assistance and falls had occurred as a result, residents who required assistance with eating would have their meals delayed, showers were often missed, medications at times were delayed and behavioral altercations took place in common areas when staff were attending to individual residents.

On 3/13/21, LPA conducted an in-person facility inspection , there were 20 residents in care and LPA was informed by staff present that there five residents receiving Hospice, six residents with regular behavioral disturbance, 15 Incontinent, nine who require ambulation assist or cuing for transfers or falls safety, 4 require dining assist, five require two- person assist and two are 1:1 for behaviors.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 8 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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During this inspection there were two caregivers, a med tech and two additional agency staff for two one-to-one residents present, a house keeping staff, Activities Director and the LVN present at 10 AM in the morning. Care staff and management interviewed stated that this is the proper staffing for current residents and their care needs.

Facility staff reported to LPA that on the overnight shift of 3/26/21 -3/27/21, three staff were working- S12 med tech, S13 on call caregiver until 4 AM, and caregiver S14 who left unannounced "sick" at approximately 2:20 from Cottage (wing of the facility. S2 did not inform S12 or S13 of their departure. Cottage house has residents who need frequent care, hospice residents need checks, resident repositioning (R18), residents with falls or behaviors. There were only two staff 2:20-4 PM. S14 was not known to be gone until 3:50 AM. Med tech S12 was the only staff 4-5 AM. Housekeeping arrived at 5. AM staff arrived at 6 AM.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by records and statements that found insufficient staff to meet resident needs. This posed an immediate risk to residents.

Resident’s records are incomplete – Sharon Porter LIC 602 dated 11/19/18 at the time of her 9/22/20 fall with compression fracture. A residents’ record review of LIC 602 Physician Reports, which are required annual and for significant change of condition for residents with dementia, were more than 12 months old for R1, R3, R5 and R19 at the time of recorded falls or behavioral incidents.
87705 Care of Persons with Dementia (e) (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by records review with found of five of eight records reviewed has expired annual medical assessments. This posed a potential risk to residents.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 7 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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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 Sharon Monck to sign. Administrator to send a signed copy back to CCL.
Additionally, LPA sent a copy of the appeal rights.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 6 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evident from records and statements that R12 was not	1 2 3 4 5 6 7	Licensee will conduct daily audits of their PCC recording systen beginning 4/20/21. Additionally, licensee will develop a shdowing and compitency evaluation system to be submitted to LPA by 5/5/21 by the POC.
	8 9 10 11 12 13 14	provided medication. This poses an immediate risk to residents in care. This is a repeat violation in 12 months.	8 9 10 11 12 13 14	Civil penalties to be issued.
Request Denied Type A 04/26/2021 Section Cited CCR 87464	1 2 3 4 5 6 7	Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living... This requirement was not met as evidenced by facility records and staff statements that as staff shortages delayed residents	1 2 3 4 5 6 7	Licensee will conduct daily audits of resident care needs having been met by care staff. Licensee will submit detailed care tasks lists for current residents to LPA by the POC date of 4/26/21.
	8 9 10 11 12 13 14	dressing, eating, bathing and assistance with taking prescribed medications. This posed an immediate risk to residents	8 9 10 11 12 13 14

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 9 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Request Denied Type A 04/21/2021 Section Cited CCR 87411	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by records and statements that found insufficient staff to meet resident needs. This posed an immediate risk to residents.	1 2 3 4 5 6 7	Licensee will submit a statement that the staffing configuration discussed today will be maintained until the facility completes a comprehensive analysis to develop staffing needs. This statement will be submitted by the POC date of 4/21/21.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14	If the facility formula for determining staffing needs changes from their existing plan of operations, tha changes will be submitted to CCL for approval.
Type B 05/05/2021 Section Cited CCR 87219	1 2 3 4 5 6 7	87219 Planned Activities (e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member,...who has the primary responsibility for... planned activities. This requirement was not met as evidenced by records and statements an activities director was not present at the facility Sept 2020- March 2021.	1 2 3 4 5 6 7	Licensee will submit a statement of understanding of this requirement to include a plan to notify CCL of this position becomes vacant, tio LPA by the POC date of
	8 9 10 11 12 13 14	This posed a potential risk to residents.	8 9 10 11 12 13 14

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 10 of 13

Control Number 27-AS-20200928100545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87705(e)(5)	1 2 3 4 5 6 7	Care of Persons with Dementia (e) (5) Each resident with dementia shall have an annual medical assessment..., and a reappraisal done at least annually...This requirement was not met as evidenced by records review with found of five of eight records reviewed has expired annual medical assessments. This posed a potential risk to residents.	1 2 3 4 5 6 7	Licensee will submit a statement of those current residents whose medical assessments and appraisals are current as well ass the timeline for the remaining residents' to be made current, to LPA by the POC date of 5/5/21.
	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
	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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 11 of 13

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 27-AS-20200928100545

FACILITY NAME:	BROOKDALE CITRUS HEIGHTS		FACILITY NUMBER:	347003712
ADMINISTRATOR:	SCARBERRY, JENNIFER		FACILITY TYPE:	740
ADDRESS:	7375 STOCK RANCH RD		TELEPHONE:	(916) 729-2722
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	56	CENSUS: 20	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sharon Monck		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff falsifying residents medical records
Staff did not notify residents authorized representatives of incidents

INVESTIGATION FINDINGS:

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On 4/19/21, Licensing Program Analyst (LPA) Kevin Mknelly spokewith Sharon Monck of Brookdale Citrus Heights at approximately 2 PM.
LPA was unable to meet at the facility due to current circumstances.

LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. While errors and omissions were noted in resident electronic reporting, there was not sufficient evidence to find that staff falsifying residents’ medical records. Furthermore, statements from staff and records reviewed were inconsistent regarding which resident incidents and issues were reported to responsible parties as required.As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A 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.

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 12 of 13

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 27-AS-20200928100545

FACILITY NAME:	BROOKDALE CITRUS HEIGHTS		FACILITY NUMBER:	347003712
ADMINISTRATOR:	SCARBERRY, JENNIFER		FACILITY TYPE:	740
ADDRESS:	7375 STOCK RANCH RD		TELEPHONE:	(916) 729-2722
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	56	CENSUS: 20	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sharon Monck		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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8
9

Residents sustained multiple fractures due to falls.

INVESTIGATION FINDINGS:

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On (date), Licensing Program Analyst (LPA) Kevin Mknelly spoke with Sharon Monck of Brookdale Citrus Heights at approximately 2 PM.
LPA was unable to meet at the facility due to current circumstances.

LPA reviewed staff records, facility records, and conducted interviews.LPA finds that facility met Tittle 22 requirements. While multiple resident falls were found to have occurred, evidence was found for only one fracture to R1 on 9/22/20.
This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Sharon Monck to sign. Administrator to send a signed copy back to CCL.
Additionally, LPA sent a copy of the appeal rights.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 13 of 13