347005467-6-27-2021-27-AS-KMKY-C4FQHJ-20210629121111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 06/27/2021
Date Signed: 06/27/2021 12:01:22 PM

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
10/07/2020 and conducted by Evaluator Michael Reber

COMPLAINT CONTROL NUMBER: 27-AS-20201007154720

FACILITY NAME:	BROOKDALE FOLSOM		FACILITY NUMBER:	347005467
ADMINISTRATOR:	ED SILVA		FACILITY TYPE:	740
ADDRESS:	780 HARRINGTON WAY		TELEPHONE:	(916) 983-9300
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	130	CENSUS: 70	DATE:	06/27/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Maurissa Eidenshink, Business Office Coordinator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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- Resident sustained injuries due to a fall caused by facility hazards.
- Facility did not safegaurd residents belongings.
- Resident was denied access to a phone.

INVESTIGATION FINDINGS:

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On 6/27/21, Analyst, Mike Reber met with Business Office Coordinator, Maurissa Eidenshink. 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 incident report obtained by this analyst reports that a resident (R1) received injuries and was sent to the hospital when she experienced an unwittnessed fall on 8/14/20. A staff (S1) discovered R1 lying on the floor in a hallway between the dining room and the living room when she heard R1 hit to the ground. In an interview with S1 on 5/1/21, S1 states that she did not observe water on the floor nor had the floor been recently mopped. Analyst observed that the incident report did not state the floor was wet. Analyst attempted to speak to R1 and the reporting party but was unsuccessful in all attempts. Analyst is unable to determine that a wet floor was the cause of R1 experiencing a fall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (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: 1 of 3

Control Number 27-AS-20201007154720

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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**************************************Report is continued from LIC 9099******************************************

Facility did not safeguard residents belongings
The reporting party states that a $1,500 Mac Book Laptop had gone missing while R1 resided at the facility. Analyst reviewed R1 file and did not observe any documentation regarding resident property and valuables. An interview with a staff (S2) on 5/3/21, indicates that upon discharge they packed up R1 belongings and a laptop was not present at that time. Interviews with two staff (S2 and S3) indicate that R1 would leave to visit her husband and are not sure if R1 took the laptop with her during the visits. Facility staff state that when they were approached by RP about the missing laptop they attempted to help locate the device but RP refused to cooperate in utilizing the "Find my device" feature on the product. Analyst attempted to reach the RP and R1 to obtain more details on the missing device but was unsuccessful. Based on the information obtained, there is insufficient evidence to determine if the facility failed to safeguard resident belongings.

Resident was denied access to a phone.
Interviews with four staff and the resident's son indicate that the resident had a personal cell phone upon entering the facility. In an interview with the memory care director, the phone was taken from the resident 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. All staff interviewed stated that R1 was able to use the facility phone to make calls to the family and the son stated that he had been able to speak with his mother by phone as well. Analyst was unable to speak with the reporting party or resident regarding the allegation and based on the incomplete evidence obtained there is insufficient evidence to determine that the resident was denied access to a phone.

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.

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
10/07/2020 and conducted by Evaluator Michael Reber

COMPLAINT CONTROL NUMBER: 27-AS-20201007154720

FACILITY NAME:	BROOKDALE FOLSOM		FACILITY NUMBER:	347005467
ADMINISTRATOR:	ED SILVA		FACILITY TYPE:	740
ADDRESS:	780 HARRINGTON WAY		TELEPHONE:	(916) 983-9300
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	130	CENSUS: 70	DATE:	06/27/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Maurissa Eidenshink, Business Office Coordinator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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- Facility did not provide personal privacy during telephone conversations.

INVESTIGATION FINDINGS:

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R1 resided at the facility from July 2020 through September 2020. During this time the facility was observing strict COVID-19 protocols to help mitigate the spread of the virus and to keep the residents and staff safe. In order to safely allow visits with family members and loved ones, the facility conducted "window visits" in which residents would speak with family members on the telephone as they were on the other side of the window of the dining room. This allowed residents and family members to see and talk to each other while remaining safe. Due to R1 diagnosis of dementia, the operation of the phone was at times difficult for the resident and often times R1's husband requested the speaker phone be put on to minimize the difficulty of R1 using the phone. To properly facilitate the visits, staff would stand nearby to assist the resident when they experienced difficulty with the visits.

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 Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (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: 3 of 3