347005512-8-28-2020-27-AS-SDOB-BTATV7-20200909150325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 08/28/2020
Date Signed: 08/28/2020 06:01:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2020 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200407145448

FACILITY NAME:	BROOKDALE ELK GROVE		FACILITY NUMBER:	347005512
ADMINISTRATOR:	JERICA HOWARD		FACILITY TYPE:	740
ADDRESS:	6727 LAGUNA PARK DR		TELEPHONE:	(916) 683-1881
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	108	CENSUS: 55	DATE:	08/28/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jerica Howard		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident's toileting needs are not being met

Lack of staffing

Facility staff failing to follow physician's orders

INVESTIGATION FINDINGS:

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Unannounced complaint visit was made out to this facility via telephone since a physical visit was unable to be made at this time due to COVID 19 related concerns. This LPA was able to speak with the interim facility designated Administrator Edward Silva.
Current census was 55 residents.
The purpose of this visit was to deliver the findings for this complaint investigation pertaining to the above allegations.
Based on interviews and a review of the documents obtained during the course of this investigation, it was learned that the resident, R1, was initially admitted into this facility back in the year 2015. From this admission date, it was clearly noted on the LIC 602 that R1 was incontinent of bladder but not bowel. As a result, this facility instituted a toileting plan to meet R1's care needs involving toileting R1 on a regular basis, checking R1 to maintain skin integrity, and communicating any additional needs to fellow staff and all involved parties. It was observed that there was no history of skin breakdown for R1 ever since the admission date.
Based on interviews, it was learned that the Elm Cottage was used to accept and retain residents diagnosed with dementia. This cottage was staffed with (3) caregivers for the AM shift, (3) caregivers for the PM shift, and (1) caregiver for the NOC shift. All three shifts also had a dedicated Medication Technician whose main

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020

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 27-AS-20200407145448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE ELK GROVE	FACILITY NUMBER: 347005512
	VISIT DATE: 08/28/2020

NARRATIVE

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priorities were to maintain the medication administration record, properly dispense and record the medications for the residents, and maintain proper communication with doctors, family, and facility personnel in regards to any changes for the residents' medications. It was learned that facility staff felt that these staff to resident ratios allowed for adequate care and time dedicated to each resident. Staff did not feel stressed or rushed as they attempted to provide Activities of Daily Living unto the residents.
Based on a review of the facility documents and records, it was observed that a personal care plan was conducted on a quarterly, semi-annual, or annual basis depending on the care needs of the resident and if any observable changes were noted. It was observed that several care plans were created and adjusted from the date of admission, 11/27/2015, until the present for R1. These care plans were created to address any changes to the physical, mental, and overall care needs of the resident which might have reflected a change in the basic rate and other fees associated to these changes.
It was observed that R1 was denoted as being a fall risk upon admission and placed on a fall prevention program by this facility. This program put staff and settings into place to attempt to reduce the number of falls that this resident could possibly sustain and to also limit the amount of harm that could result from such falls.
A review of the records revealed that this facility maintained and tracked documents whenever a resident was ordered by their primary care physician to undergo a change in medications or attain other forms of treatment. This was true for resident, R1, as observed by the various Temporary Service Plans which ranged from the initial treatment ordered on 12/11/2017 until the most recent one on 02/20/20.
These treatments ranged from antibiotics ordered for an infection to changes in medications for a UTI. It was observed that these documents were filled out with a follow up plan for the facility staff to follow. This usually entailed taking vitals for a designated number of days and charting in the resident's binder for a designated amount of time. It was observed that all care staff responsible for these duties were made to initial on their day of care that was provided to the resident.
It was observed that a clear plan was devised according to the instructions of the physician. Documentation was performed for the care ordered and properly initialed by the facility care staff.
This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint.
There were no deficiencies observed or cited during today’s complaint visit. A copy of this report will be emailed, with a read receipt, to the facility designated Administrator and copy sent to the corporate office address as well. Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020

LIC9099 (FAS) - (06/04)

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