347005467-10-4-2023-59-AS-KHOS-CWGLSZ-20231010090133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 10/04/2023
Date Signed: 10/04/2023 09:53:20 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230718132033

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: 102	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Health and Wellness Director: Sharisse Toves		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff did not adequately supervise residents resulting in a resident hitting another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/04/2023 to deliver complaint finding Community Care Licensing received on 07/18/2023. LPA met with Health and Wellness Director, Sharisse Toves, and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews with facility staff and reviewed pertinent documentation such as, residents’ (R1 and R2) physician’s report, service plan, SOC 341, staff schedule, and police report.

Continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230718132033

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE FOLSOM	FACILITY NUMBER: 347005467
	VISIT DATE: 10/04/2023

NARRATIVE

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According to police report, police officer responded to a call for possible domestic violence on 7/18/2023. R1 and R2 are diagnosed with Dementia. An incident occurred on 7/16/2023 around 6 PM, a staff was assisting R1 and R2 into bed. R2 was being uncooperative with staff and R1 got frustrated and slapped R2 across the face. R2 grabbed onto R1’s arm. There were no injuries and family were called. There are some minor incidents where R1 may be frustrated during mealtime and kick R2’s foot under the table. Interview with staff indicated facility’s management has a plan in place to redirect R1 during a behavioral outburst. According to R1’s service plan, R1 displays aggressive and obsessive behavior with R2 at times requiring staff attention and intervention. Interviews conducted with staff indicated, staff would conduct rounds to check on R1 and R2 every hour.

The Department conducted a thorough investigation, there was no evidence to suggest that the facility was negligent in their care and did not adequately supervise residents resulting in R1 hitting R2. Staff was present during the time of the incident and redirected residents right away.

The Department could not find enough evidence to confirm nor deny this allegation happened. The Department finds this allegation to be UNSUBSTANTIATED - meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies being cited for today’s visit.

Exit interview conducted and report left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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