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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:01:13 PM


Document Has Been Signed on 02/15/2022 12:01 PM - It Cannot Be Edited

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 FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 97DATE:
02/15/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kristine Clawson, AdministratorTIME COMPLETED:
12:15 PM
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On February 15, 2022, Licensing Program Analyst (LPA) Bethany Mirlohi met with Administrator of facility Brookdale Folsom, Kristine Clawson, at approximately 11:45 AM. LPA 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: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
Today’s visit is a case management visit to follow-up on a complaint investigation that came into the Department on September 7, 2021 and was completed on September 10, 2021.
On September 10, 2021, the Department delivered complaint findings to the facility, which substantiated that a facility staff (S1) physically abused a resident (R1). During the investigation of the complaint, the Department reviewed video surveillance that was recorded on September 2, 2021 at 6:32 p.m., which shows S1 slapping R1 on the face as well as pulling and grabbing R1’s hair. In addition, S1 was observed on video roughly placing R1 in bed with Staff (S2) assistance.
Video surveillance was located in R1’s room which was installed by R1’s representative on the evening of September 2, 2021. The Department learned that the family of R1 installed a hidden camera out of concern for R1.

Continuation on 809-C.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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 FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 02/15/2022
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On September 10, 2021, Deficiencies were cited for violating California Code of Regulations, Title 22 Division 6, Chapter 8, §87468.1(a)(1) Personal Rights of Residents in All Facilities, Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. Additionally, the facility was also cited for California Code of Regulations, Title 22, division 6, Chapter 8, §87468.1(a)(3) Personal Rights of Residents in All Facilities, Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
Based on observation and interviews, the licensee did not ensure R1 was free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature which resulted in R1 being physically abused by facility staff.
On September 30, 2021, the Department issued an immediate civil penalty for $500 and the Administrator was informed that a civil penalty assessment based on Health and Safety Code § 1569.49 is currently under review (pending determination) and may be assessed on a later date.
Today, February 15, 2022, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49, for a violation that the Department constitutes as physical abuse in the amount of $9,500.00.
A copy of the LIC 421D was given to Kristine Clawson and originals were signed.
Exit interview conducted. Appeal Rights provided. A copy of the report issued. Kristine Clawson signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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