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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 03:25:40 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
04/15/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220415161750
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 did not distribute resident's self administered medications as prescribed
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 pre screening, and wore surgical masks while at facility. LPA and LPM were screened by Front Desk.

ALLEGATION: Staff did not distribute resident's self administered medications as prescribed
During the complaint investigation, a review of medication documentation was conducted for 10 residents. Based on the sample review, it appears staff are administering medications as prescribed however, R1 stated in an interview that it was unclear as to whether R2 was given medications. 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 cited/ Exit interview and copy of report provided.
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
04/15/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220415161750

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: DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not observe resident for change in condition
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 pre screening, and wore surgical masks while at facility. LPA and LPM were screened by Front Desk.

ALLEGATION: Staff did not observe resident for change in condition
During the complaint investigation, records were reviewed and interviews were conducted. LPA observed staff documentation and notification to R1's physician when R1's change in condition occurred. In addition, the facility sent R1 out to the hospital due to a change in condition as well. Based on the investigation, the allegation above is UNFOUNDED meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.
No deficiencies cited/ Exit interview and copy of report provided.
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