347005512-7-3-2021-27-AS-KHOS-C4NPZV-20210706114610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 07/03/2021
Date Signed: 07/03/2021 03:06:33 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
06/15/2020 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200615162308

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: 45	DATE:	07/03/2021
		UNANNOUNCED	TIME BEGAN:	12:49 PM
MET WITH:	Amanda Stewart		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff did not assist in transferring resident as needed.
Facility did not ensure resident's room was clean.

INVESTIGATION FINDINGS:

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LPA Johnson made an unannounced visit to this facility to deliver findings for the above mentioned allegations.

Allegation: Facility staff did not assist in transferring resident as needed.
Based on records reviewed and interviews conducted the department has discovered that R1 was not transferred from her bed unless it was for showering twice weekly, as a result of this R1 was confined to the bed and not assisted with transferring to the wheelchair or a walker to aid in mobility. R1's service plan dated 10/28/2018, confirms that R1 was to have assistance with using the bathroom approximately every two to four hours during the day and as needed during the night and was to be transferred to the recliner for meals.

Continued

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2021

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-20200615162308

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: 07/03/2021

NARRATIVE

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The assessment confirmed that R1 was oriented to person, place, time and was able to communicate needs and preferences (verbally or non-verbally). The facility was unable to provide LPA with a more recent or up-to date assessment from the assessment dated 10/28/2018. R1 moved out of the facility on 2/1/2020. The actions of transferring as mentioned in the assessment dated 10/28/2018 were not met as a result the allegation is substantiated.

Allegation: Facility did not ensure resident's room was clean. Based on records reviewed and photos the department was able to establish that R1's carpet was not clean when R1 moved out on 2/1/2020. The photos show three large carpet stains and several other smaller stains, used tissues that were behind furniture in the room (tissues were exposed because the furniture was moved out of the room at the time of the photos 2/1/2020). The facility was unable to provide the department with maintenance records for carpet cleaning, filter changing and other records related to basic cleaning services. The department finds the allegation to be substantiated.

The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Amanda Stewart. Appeal rights and report given.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200615162308

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/05/2021 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care.	1 2 3 4 5 6 7	Licensee to schedule and conduct an in-service training on basic services, and care and supervision. Copy of training materials and list of attendees due to CCL. Training to be scheduled by 7/5/2021
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: lack of actions of transferring as mentioned in the assessment dated 10/28/2018. This poses an immediate health and safety risk to resident.	8 9 10 11 12 13 14
Type B 07/16/2021 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will maintain records for carpets cleaned as well as other maintenance records to establish that the facility is being kept clean and in good repair.
	8 9 10 11 12 13 14	Based on photos and lack of maintenance records the licensee did not maintain the facility grounds. The facility had dirty carpets and debris in R1's room (photos taken). This poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	The facility will provided the resident council and CCL with a cleaning schedule for the windows and carpets by the POC date 7/16/2021

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2021

LIC9099 (FAS) - (06/04)

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