347005467-9-10-2021-25-AS-LMUZ-C7CN7J-20210930101249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 09/10/2021
Date Signed: 09/10/2021 01:39:51 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
09/07/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20210907101306

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: 89	DATE:	09/10/2021
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Kristine Clawson, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff hits a resident while in care
Staff inappropriately pulled a resident's hair while in care
Staff mistreats a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with administrator Kristine Clawson. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
During investigation, LPA interviewed staff and conducted a staff and resident file review. LPA interviewed administrator in which they stated a family member had a hidden camera in R1's room in which facility was unaware of. Administrator was informed by family member on 9/3/21 that staff was observed treating R1 roughly on video surveillance on 9/2/21.
Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

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 25-AS-20210907101306

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: 09/10/2021

NARRATIVE

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Administrator reviewed surveillance video and observed Staff (S1) hit R1 on the side of the face and pull their hair. In addition S1 was observed roughly placing R1 in bed with Staff (S2) assistances. S1 was observed throwing a blanket over R1's face and turning on and off the bedroom lights. S2 was not observed being rough with R1 however S2 did not report abuse to management or other staff.
Police department, ombudsman, and CCL was notified of the incident on 9/3/21. Administrator stated S1 and S2 were immediately removed from facility and no longer work at the facility. Administrator conducted staff training on 9/8/21 for all staff in regards to abuse, neglect and mandatory reporting.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies have been cited on 9099-D.

Exit interview conducted and appeal rights given.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20210907101306

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: 09/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/10/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	Administrator conducted a training for all staff on abuse, neglect, and mandate reporting on 9/8/2021. In addition S1 and S2 no longer work at the facility. Copy of training was obtained.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview the licensee did not ensure that resident was afforded their personal rights which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Document amended
Type A 09/10/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Administrator conducted a training for all staff on abuse, neglect, and mandate reporting on 9/8/21. In addition S1 and S2 no longer work at the facility. Copy of training was obtained.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview the licensee did not ensure residents were treated with dignity which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Document amended

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC9099 (FAS) - (06/04)

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