347005467-1-10-2022-25-AS-KHOS-CAUMFU-20220120083455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 01/10/2022
Date Signed: 01/10/2022 03:30:29 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
09/10/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20210910124944

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: 91	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kristine Clawson, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident was left unattended on the floor for an extended period of time after falling.
Facility did not have sufficient staff to meet resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced and met with Administrator Kristine Clawson. LPA arrived to deliver findings into complaint allegations listed above. LPA's 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: Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, “Resident was left unattended on the floor for an extended period of time after falling.” LPA conducted interviews with staff and relevant parties, reviewed resident information, and reviewed video footage. LPA reviewed facility documentation in which it states resident had an unwitnessed fall on 9/6/21 and was found at approximately 7:40 am.
Continuation on 9099-C.

Unsubstantiated

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: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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

Control Number 25-AS-20210910124944

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: 01/10/2022

NARRATIVE

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It is documented staff checked on resident at approximately 7 am and resident was in bed. Notes indicate resident refused assistance to get up from the ground, and emergency services were contacted to conduct a lift assist. LPA obtained calls of service from Fire department which states they were called at 8:06 am and arrived at the facility at 8:12 am. Document states it was a non-injury fall and they assisted resident up from the floor and into bed. Relevant party stated resident was left alone on the floor for approximately 30 minutes after a fall until medical emergency services arrived. LPA obtained video footage, and the angle of the camera shows a small part of the resident room. Through video footage LPA is unable to determine if resident was left unattended on the floor for a long period of time. LPA interviewed 6 staff members from the facility. 6 of 6 staff stated facility policy when a resident is found from a fall is to remain with resident until assessment is completed by med tech and/or medical emergency services have arrived. LPA interviewed 2 caregivers on schedule for 9/6/21, and both did not recall specific information about resident’s fall. LPA interviewed 1 medication technician (med tech) on schedule for 9/6/21 and stated resident had a fall and med tech was called into resident room to complete an assessment. No injuries were noted but emergency services were called for assistances with transfer of resident. Med tech stated caregiver stayed with resident whiles emergency services were called. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.
LPA investigated allegation, “Facility did not have sufficient staff to meet resident's needs”. LPA conducted interviews with staff and relevant parties, reviewed resident information and staff schedule. LPA interviewed administrator in which they stated they scheduled 2 caregivers and 1 med tech on the AM and PM shift and 2 caregivers for the night shift for the memory care unit. Administrator stated even though 2 caregivers were let go due to an incident addressed in complaint #25-AS-20210907101306, they were able to cover their shifts.
Continuation 9099-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 25-AS-20210910124944

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: 01/10/2022

NARRATIVE

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LPA interviewed 5 staff in which they stated during the period of 2 caregivers being let go they always were fully staffed and had sufficient staffing. Interviews with caregivers indicate they are able to meet the needs of the residents with their current staffing levels. LPA reviewed staff schedule for August and September 2021 and observed 2 caregivers and 1 med tech scheduled for AM and PM shift and 2 caregivers for night shift with 1 shared 1 med tech at night for memory care unit and the assisted living side. LPA interviewed relevant party in which they stated when they have been present at facility there have been 2 caregivers, 1 med tech, and the manager of the memory care present. Relevant party had concerns about staff meeting the care needs of the resident and indicated facility did not have enough staff in the memory care unit. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 3 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
09/10/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20210910124944

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: 91	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kristine Clawson, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident was not treated with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced and met with Administrator Kristine Clawson. LPA arrived to deliver findings into complaint allegations listed above. LPA's 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: Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, “Resident was not treated with dignity”. LPA interviewed staff, relevant party, and reviewed facility documents. Allegation is in reference to an incident addressed in complaint #25-AS-20210907101306. 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: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 25-AS-20210910124944

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: 01/10/2022

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 regard to abuse, neglect and mandatory reporting. Due to the information gathered LPA finds allegation to be SUBSTANTIATED. Facility was cited on 9/10/21 in regards to this incident.

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.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5