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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 01/10/2022
Date Signed: 01/10/2022 03:26:35 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
11/03/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20211103131525
FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 91DATE:
01/10/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kristine Clawson, Administrator TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff did not make resident's records available to the authorized representative in a timely manner.
Facility did not have a signed admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced and met with Administrator Kristine Clawson. LPA arrived to deliver findings into complaint allegations listed above. LPA's completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, “Staff did not make resident's records available to the authorized representative in a timely manner.” LPA interviewed administrator, responsible party (RP), and reviewed documents. Relevant party indicated facility did not produce resident records within the required 2 business days.
Exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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 5
Control Number 25-AS-20211103131525
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 FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 01/10/2022
NARRATIVE
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LPA interviewed responsible party in which they stated they requested resident records on Thursday September 16, 2021 and picked up documents on September 23, 2021. Responsible party stated facility requested 4 days to produce documents and RP stated they did not have a specific deadline in which documents needed to be produced and agreed. LPA reviewed documentation which shows on September 17, 2021 staff emailed responsible party requesting for a “Authorization for Release of Brookdale Health Care Records” to be signed and sent back to facility. “Authorization for Release of Brookdale Health Care Records” form is electronically signed by Responsible party and dated on September 20, 2021. Interviews with administrator indicated Responsible party picked up resident records on September 23, 2021. Although facility did not produce resident records within 2 business days, Responsible party stated they agreed to a later time frame. Due to the information gather, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, “Facility did not have a signed admission agreement”. LPA interviewed administrator, responsible party (RP), and reviewed documents. Interviews with administrator indicate an admission agreement was signed with RP upon the time of admission for the resident. LPA interviewed RP in which they stated they signed a document upon admission of resident but could not specifically remember the document. LPA reviewed admission agreement on file and observed RP signed admission agreement on 8/20/21 and administrator signed admission agreement on 8/21/21. Due to the information gather, LPA finds allegation to be UNFOUNDED.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/03/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20211103131525

FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 91DATE:
01/10/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kristine Clawson, Administrator TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Resident's records were incomplete.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced and met with Administrator Kristine Clawson. LPA arrived to deliver findings into complaint allegations listed above. LPA's completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, “Resident's records were incomplete.” LPA interviewed administrator, responsible party (RP), and reviewed documents. On 11/4/2021 LPA reviewed R1’s resident file and observed all required documents in resident file. Relevant party stated the documents that were received from facility on September 23rd were incomplete, and facility did not provide RP with all resident records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20211103131525
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 FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 01/10/2022
NARRATIVE
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Administrator provided LPA the documents sent to RP, and LPA observed admission agreement, documents on medications, and other resident documents were not provided to RP on September 23, 2021. Due to the information provided LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations 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.

Deficiencies cited on 9099-D.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20211103131525
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 FOLSOM
FACILITY NUMBER: 347005467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2022
Section Cited
CCR
87468.2
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
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Administrator agrees to release all resident documents to resident representative. Administrator to show LPA proof all records have been released by 1/17/22.
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This requirement is not met as evidenced by: Based on record review the licensee did not release all of resident records which poses a potential health and safety risk to resident's in care.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5