347005467-3-6-2024-59-AS-MSEY-D3AKVJ-20240312081423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:30:40 PM

Substantiated

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
03/04/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240304081051

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: 93	DATE:	03/06/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Kristine Clawson, Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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-Facility mismanaged resident's medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 3/6/24, and met with the Executive Director, Kristine Clawson, to open a complaint investigation and deliver findings into the above stated allegation.

During today's visit, LPA obtained documentation pertinent to the investigation and conducted a medication count for 3 residents.

************************************************Continued on LIC9099-C*************************************************

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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-20240304081051

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: 03/06/2024

NARRATIVE

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LPA conducted a medication count for residents (R1, R2 & R3), comparing the residents' medication lists on file with medication centrally stored for the residents.

LPA observed one (1) medication for R1 that was over the amount documented and there were four (4) medications for R1 that were under the amount documented. LPA observed five (5) medications for R2 that were over the amount documented. LPA observed that two (2) medications for R3 were over the amount documented. LPA also observed during the medication count that there were several other residents that didn't have start dates for their medications.

According to the facility's Order Summary Report and interviews conducted with the Executive Director and Health and Wellness Director, R1 had a new prescription for Losartan Potassium 25mg tablets that was ordered by the prescribing physician on 2/27/24. Facility Progress Notes for R1 dated 2/29/24 indicated that staff (S1) contacted R1's physician's office requesting that the medication order be faxed to the pharmacy. Progress Notes dated 3/3/24 indicated that S1 contacted R1's responsible party informing them that the facility was having issues getting the new prescription filled. Progress Notes also indicated that R1's responsible party would provide R1 with the their discontinued medication until the facility was able to get the new prescription filled. R1 did not begin receiving their new prescription until 3/5/24, which was 7 days after the original physician's order date of 2/27/24.

Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240304081051

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/07/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to have all med-techs sign a statement of understanding of job duties to address medication management to submit to LPA by the POC due date of 3/7/24. Faciliy will also complete bi-weekly audits of all medications for the next month and submit to LPA.
	8 9 10 11 12 13 14	Based on medication count and records reviewed, the facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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