347005467-4-14-2022-25-AS-TORZ-CE2P35-20220502105654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:22:15 PM

Unsubstantiated

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
10/01/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20211001093040

FACILITY NAME:	BROOKDALE FOLSOM		FACILITY NUMBER:	347005467
ADMINISTRATOR:	KRISTINE CLAWSON		FACILITY TYPE:	740
ADDRESS:	780 HARRINGTON WAY		TELEPHONE:	(916) 983-9300
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	130	CENSUS: 104	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Kristine Clawson, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident sustained fracture while in care.
Staff are not responding to residents call button in a timely manner.
Facility's response system is in disrepair.
Facility does not have adequate staffing to meet the needs of the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced and met with Administrator Kristine Clawson. LPA arrived to continue investigation 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.
The department investigated allegation, “Resident sustained fracture while in care.” On 8/28/21, R1 sustained an un-witnessed fall in their bathroom resulting in them fracturing their left femur. R1 was found by care staff and immediately sent out to the emergency department for medical treatment.

Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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 4

Control Number 25-AS-20211001093040

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: 04/14/2022

NARRATIVE

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The department interviewed care staff, in which they stated R1 requires minimal assistance with showering, toileting and dressing. R1 is considered non-ambulatory and uses a walker to get around the facility. R1 was provided a call button which they wore around their neck to call for help if needed. Per the facility call button records, there is no record of R1 pressing their call button on 8/28/21. R1 attempted to use the restroom on their own without pushing their call button, resulting in R1 sustaining the fall.
Per care staff, R1 is instructed to punch their call button for any services they may need assistance with. Per facility call button history, R1 understood this and would push their call button daily if not multiple times a day. Although R1 did sustain a fracture while in care, the department is unable to determine if it was due to facility neglect. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.
The department investigated allegation, “Staff are not responding to residents call button in a timely manner.” On 8/28/21, R1 sustained an un-witnessed fall in their bathroom resulting in them fracturing their left femur. R1 was found by care staff and immediately sent out to the emergency department for medical treatment.
The department reviewed call button history for R1 for the past six months, from February 2021 to August 2021. The call button history showed R1 pressing their button daily if not multiple times a day, which shows R1 had a cognitive understanding on how to operate the call button. Based on the call button records, R1 did not push their call button on 8/28/21 to call for help. Call button records show which room is requesting assistance, and at what time and on what date.
LPA interviewed 5 clients in care in which they stated at times caregivers arrive in a timely manner once they push their button and at times it takes over 30 minutes to respond.

Continuation on 9099-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20211001093040

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: 04/14/2022

NARRATIVE

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Clients stated the facility needs more staff in order to respond in a timely manner more consistently. 1 client, R2, stated in the Fall of 2021, they had a fall and waited on the ground for over 1 hour until a caregiver responded. LPA interviewed a caregiver which was on shift during R2’s fall incident, and they did not remember the fall incident. LPA interviewed administrator in which she stated they are in the process of hiring more staff for both the AM shift and PM shift. Due to the information gathered, the department finds allegation to be UNSUBSTANTIATED.
The department investigated allegation, “Facility's response system is in disrepair.” LPA interviewed staff, administrator and clients in care. LPA interviewed Administrator in which she stated residents have pendants, caregivers have a pager, and all the calls go to a computer in the med tech room. Residents will press the pendent and the call goes to the caregiver pager and the computer in the med tech room. At times the battery’s get low in the resident pendants, however Administrator runs a report weekly which states which pendant batteries are getting low. Administrator reports that either she or the maintenance director will change the batteries. LPA interviewed 5 care staff, in which 4 of 5 care staff stated resident pendant batteries do die at times and the care staff are unaware of when this occurs. Resident will either contact front desk or stop staff in the hallways to inform them that no one has responded to their call light. Care staff stated over all the pendant system does work when resident’s press their pendants. LPA interviewed 5 residents’ in care, in which they stated their pendants work however at times it takes a long period of time for staff to respond to call lights. Due to the information gathered, LPA finds allegation to be UNSUBSTANTIATED.
The department investigated allegation, “Facility does not have adequate staffing to meet the needs of the residents.” LPA interviewed staff, administrator and clients in care. LPA interviewed administrator in which she stated there are 2 caregivers and 1 med tech per shift for the Am shift and 2 caregivers for the PM shift on the assisted living side of the facility. In addition, recently administrator has hired a mid-shift caregiver that works 11 am to 7 pm to help both shifts. Administrator stated they are now going to hire a 3^rd caregiver for both shifts now that there are more residents with care needs. LPA reviewed staff schedules and observed 2 caregivers per AM and PM shift on schedule.
Continuation on 9099-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20211001093040

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: 04/14/2022

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LPA interviewed 5 care staff in which they stated there are 2 caregivers per AM and PM shift and 1 med tech on schedule. Care staff stated recently there has been a mid-shift caregiver available from 11 AM to 7 PM. During the AM and PM shifts when caregivers take their lunch break only 1 caregiver and 1 med tech is available for residents. LPA interviewed 5 residents in care which they stated at times caregivers arrive in a timely manner once they push their button and at times it takes over 30 minutes to respond. Clients stated the facility needs more staff in order to respond in a timely manner more consistently. 1 client, R2, stated in the Fall of 2021, they had a fall and waited on the ground for over 1 hour until a caregiver responded. LPA interviewed a caregiver which was on shift during R2’s fall incident, and they did not remember the fall incident. Due to the information gathered, LPA was unable to find a specific incident in which indicates facility does not have adequate staffing to meet the needs of the resident. LPA finds the allegation to be UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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