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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:20:15 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
03/04/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220304121236
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: 105DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Kristine ClawsonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to meet resident's showering needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM), Laura Munoz , arrived at the facility unannounced on 07/28/2022 to deliver complaint findings for the allegation(s) listed above. LPA and LPM conducted COVID-19 Precautionary prescreening, and wore surgical masks while at facility. LPA and LPM were screened by Front Desk.

ALLEGATION: Facility staff failed to meet resident's showering needs
On 12/21/21, the hot water boiler went out. The facility did not have hot water for approximately 4 hours and was repaired on 12/21/21. Although the facility fixed the hot water within a reasobnable amount of time, there is a lack of information as to whether residents showering needs were met. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

No deficiencies are cited as a result of this complaint.
Exit interview and copy of report provided to Kristine Clawson, Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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 2
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
03/04/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220304121236

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: 105DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Kristine ClawsonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging resident (s) medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM), Laura Munoz , arrived at the facility unannounced on 07/28/2022 to deliver complaint findings for the allegation(s) listed above. LPA and LPM conducted COVID-19 Precautionary prescreening, and wore surgical masks while at facility. LPA and LPM were screened by Front Desk.

ALLEGATION: Staff are mismanaging resident (s) medications
During the course of the investigation, a medication audit was conducted. A sample review of medications and medication records were reviewed as well as interviews were conducted. The investigation found that facility staff are following medication policies and procedures therefore this allegation is UNFOUNDED meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.
No deficiencies are cited as a result of this complaint.
Exit interview and copy of report provided to Kristine Clawson, Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2