347005512-6-29-2021-27-AS-SDOB-C4JMS3-20210702095116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:24:44 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
12/02/2020 and conducted by Evaluator Jason Lund

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201202135840

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; 108	CENSUS: 44	DATE:	06/29/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Executive Director James Hall		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility did not administer medications as prescribed.
Facility did not notfiy responsible party of medication refusals.
Staff are not following their training to provide effective services to resident with dementia.

INVESTIGATION FINDINGS:

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On 6/29/2021, Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to complete a complaint investigation regarding the above allegations. LPA Lund meet with Executive Director James Hall and explained the reason for the visit. Current Census 44

LPA Lund reviewed resident (R1) Unusual incident reports/Injury reports (LIC624), medication logs, correspondence and progress notes. LPA interviewed staff and witnesses regarding the above allegations.

Based on the investigation through interviews and record reviews. When R1 would refuse medications, the facility would notify R1’s daughter, who is R1’s power of attorney (POA) for medical and R1’s doctor. R1 is diagnosed with dementia and would refuse medications, the facility nurses would try redirect, comeback at a later time or call R1’s daughter to try attempt R1 into taking medications.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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 27-AS-20201202135840

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: 06/29/2021

NARRATIVE

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Based on interviews with witnesses and staff. R1 has POAs for medical and financial responsibilities. One of R1’s daughter is in charge of finances and the other daughter is in charge of medical. The facility does notify R1’s daughter who is in charge of medical of any changes to R1’s medical conditions including refusing medications.

Through interviews with staff and witness. The facility nurses try many different techniques to attempt to have R1 take R1s diabetes medications. R1 gets very irate when the nurses attempt to give R1s medications and the nurses cannot force R1 to take medications. The nurses try to redirect, comeback at another time or call R1’s daughter to give medications. R1 daughter stated that the facility nurses are very good on trying to give R1 medications.

This agency has investigated the complaint allegations. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Executive Director James Hall and a copy of report was left.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

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