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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 06/27/2021
Date Signed: 06/27/2021 12:06:17 PM

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: 70DATE:
06/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maurissa Eidenshink, Business Office CoordinatorTIME COMPLETED:
12:45 PM
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On 6/27/21, Analyst, Mike Reber met with Health & Wellness Director, Brianna Brown. The purpose of the visit was to conduct a case management visit to address a deficiency discovered during a complaint investigation. Prior to entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.

While conducting a complaint investigation into the allegation that a resident was denied access to a phone (Complaint Control Number 27-AS-20201007154720), it was discovered that when resident (R1) was admitted to the facility she had a personal cell phone to be able to contact her family. In an interview with the memory care director, the phone was taken from the resident after a conversation with the family. The phone was confiscated due to the resident repeatedly losing the phone and the resident was also calling family at all hours of the day and this was interfering with the residents daily functioning.

Analyst observed that there was no reassessment/reappraisal of the resident after it was determined that having the phone was detrimental to the residents daily functioning. A needs and services plan was also not created for the resident to minimize the resident's behaviors in an attempt to help the resident keep the phone in her possession.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. Exit interview conducted. Copy of report and appeal rights provided to facility staff.
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2021
Section Cited

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Reappraisals - The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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This requirement has not been met as evidenced by: Based on interviews conducted and records reviewed, the administrator failed to conduct a reappraisal or implement a needs and services plan after behaviors were observed in R1. This resulted in the facility taking the residents personal phone away.
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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: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2021
LIC809 (FAS) - (06/04)
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