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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:32:17 PM


Document Has Been Signed on 09/18/2024 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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: 80DATE:
09/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sharyl Kranig, Executive DirectorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/18/24, and met with the Executive Director (ED), Sharyl Kranig, to conduct a case management visit regarding an Unusual Incident/Injury Report and SOC341 received by the Department on 9/16/24 and 9/17/24.

On Sunday, 9/15/24 at approximately 12:15pm, resident (R1) reported to facility staff that sometime during Saturday night they had been physically abused and sexually assaulted by staff (S1). The facility contacted R1's responsible party and the local police department. The police department generated a report, and R1 and responsible party refused further medical exam or treatment. R1 was examined after the incident by facility staff and there were no physical injuries observed. The facility suspended S1 until their internal investigation was completed. The facility found the allegations to be unsubstantiated. S1 is not scheduled to work at the care home on Saturday and was not present in the care home the night that the alleged incident occurred. It was discovered that R1 was watching crime related television shows, which R1's responsible party removed from their television.

On 9/17/24, R1 was taken to the hospital to be treated for potential UTI. R1 returned to the facility on 9/17/24 and was diagnosed with a UTI. R1 is scheduled to begin antibiotic medication. The facility has a meeting scheduled with R1's responsible party today, 9/18/24, and they are in the process of reassessing the resident for change in condition. Upon R1's return to the care home, the Health and Wellness Director conducted a brief interview for mental status of R1, which indicated a change in R1's cognition. The facility provided LPA with R1's hospital discharge documents, medication list, and progress notes. LPA reviewed the facility's internal investigation with ED. Staff schedule was provided to LPA as well.

During today's visit, no deficiencies were cited. Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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