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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 06/27/2021
Date Signed: 06/27/2021 11:50:03 AM



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
11/19/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20201119143630
FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:ED SILVAFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 70DATE:
06/27/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maurissa Eidenshink, Business of CoordinatorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility did not notify the authorized representative of resident's change in level of care.
INVESTIGATION FINDINGS:
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On 6/27/21, Analyst, Mike Reber met with Maurissa Eidenshink, Business Office Coordinator. The purpose of the visit was to deliver investigation findings into the above stated allegations. 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. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

An interview with the reporting party (RP) indicates that he received a phone call from the facility on October 5, 2020 notifying him that resident (R1) was more confused and disoriented than usual and that R1 was sent to the hospital for further observation and evaluation. RP states that he received a phone call the following day from the facility and they had recommended that R1 be moved to the memory care for increased supervision. RP states that he reluctantly agreed to move his father from the assisted living unit to the memory care unit during that phone call.

Based on information obtained, Analyst finds the allegations to be UNFOUNDED – a finding meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.
Exit interview conducted. Copy of report left with facility staff.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021
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 5
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
11/19/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20201119143630

FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:ED SILVAFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 70DATE:
06/27/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Brianna Brown, Health and Wellness DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff failed to safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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An interview conducted with the reporting party on 5/25/21 indicates that the R1's belongings were not inventoried upon admission to the facility. This analyst obtained facility progress notes for resident (R2) who allegedly took items from R1. The progress notes indicate that R2 exhibited behavior of going through other resident's belongings. However, due to the lack of inventory of R1 belongings, this analyst is unable to determine that any items became missing from R1 room.

Based on information obtained, Analyst finds the allegations to be UNSUBSTANTIATED - a finding 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.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.
Exit interview conducted. Copy of report left with facility staff.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
11/19/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20201119143630

FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:ED SILVAFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 70DATE:
06/27/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Brianna Brown, Health and Wellness DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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 - Lack of supervision resulting in a resident assaulting another resident while in care, causing injuries.
- Staff did not provide authorized representative with a written notice of rate increase in a timely manner.
INVESTIGATION FINDINGS:
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Lack of supervision resulting in a resident assaulting another resident while in care, causing injuries.

Interviews with staff indicate that R2 had behaviors of going into resident rooms uninvited, laying in their bed and going through other resident belongings. Progress notes for R2 revealed that on 11/2, 11/8, 11/9, 11/11, and 11/13/20, R2 wandered in other resident rooms and during some of those incidences R2 became agitated and aggressive upon redirection. In addition, on 11/1/20 R2 became "very agitated and took a swing" at a staff attempting to give R2 a shower.

On 11/9/20, the RP expressed concerns to the facility in an email about R2 walking into R1 room uninvited. RP was assured by facility staff in the email thread that it "will get addressed immediately". On 11/10/20, the RP emailed the facility again asking "Was anything found out about this?" Facility staff emailed RP regarding R2's behavior on the same day (11/10/20) stating "I can assure you that he is not trying to bother anyone on purpose he just doesn't recognize his own space." On 11/11/20, R2 injured R1 when confronted by R1 upon entering his room causing R1 to go to the hospital. Analyst obtained a Personal Service Plan for R2 and observed that exit seeking behavior was the only behavioral issue being addressed by the facility.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20201119143630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/27/2021
NARRATIVE
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Staff did not provide authorized representative with a written notice of rate increase in a timely manner.

R1's Personal Service Plan for the "Alzheimer's" unit states that R1 was moved from assisted living to the Memory Care Unit on 10/7/21. The plan indicates that the facility received "phone approval" from the reporting party on 10/10/20. R1's addendum to the original residency agreement is dated 10/14/20. An email obtained by this analyst confirms that the facility emailed the addendum to the RP on 10/14/20. These records indicate that the facility did not provide the resident’s representative, written notice of the rate increase within two business days after initially providing services at the new level of care.

Based on information interviews conducted and records reviewed, this analyst finds the allegation to be SUBSTANTIATED - a finding that means that the allegation is valid because the preponderance of the evidence standard has been met.

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: 06/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20201119143630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
06/29/2021
Section Cited
CCR
87411(a)
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Personnel Requirements - General

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

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To protect the health and safety of residents, administrator shall reassess the needs and services plan for R2 to ensure appropriate staffing and supervision are being provided based on R2's current needs. Submit updated needs and services plan to LPA with a statement of statement of understanding of this regulation by POC due date of 6/29/2021.
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This requirement has not been met as evidenced by: Based on observation and interviews conducted the facility did not address resident's (R2) aggressive behavior on the unit resulting in injury to R1. This poses an immediate risk to the resident's health and safety.
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Type B
07/09/2021
Section Cited
HSC
1569.657(a)
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Rate increase due to change in level of resident care; notice: For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care.
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Administrator shall provide training regarding this regulation to all staff involved in the process of billing and rate increases. Submit attendance sheet of staff participating in the training and a statement of understanding of this regulation to LPA by POC due date of 7/9/21.
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This requirement has not been met as evidenced by: Based on interviews conducted and records obtained, R1 was moved to memory care unit on 10/7/20, the addendum to the resident agreement was provided to the responsible party on 10/14/20. This poses a potential health and safety risk to the residents in care.
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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: 06/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5