347005467-5-10-2021-27-AS-LMUZ-C36W4N-20210519165750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 05/10/2021
Date Signed: 05/10/2021 10:57:00 AM

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
07/30/2020 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200730102935

FACILITY NAME:	BROOKDALE FOLSOM		FACILITY NUMBER:	347005467
ADMINISTRATOR:	ED SILVA		FACILITY TYPE:	740
ADDRESS:	780 HARRINGTON WAY		TELEPHONE:	(916) 983-9300
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	130	CENSUS: 73	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kristine Clawson (Admin)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not keep resident's room free from bug.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Leitzell contacted administrator Kristine Clawson to deliver complaint findings over the phone due to COVID-19 and precautionary measures.

CCL reviewed documents and conducted interviews throughout the investigation process. LPA reviewed charting notes, pest inspection reports, and spoke with staff. Through documents reviewed and interviews conducted, the above allegation is UNSUBSTANTIATED - meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred. Facility staff removed the bug from resident's room and continues to reduce the likelyhood of them returning. This was done by facilty hiring and keeping on retainer ECO-Labs for bug control.

Exit interview conducted. Copy of report sent to the facility via e-mail, Administrator to sign and return a copy to CCL either by fax or email, a copy should be retained for facility records as well

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

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 2