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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:24:09 AM



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
12/03/2020 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20201203112652
FACILITY NAME:BROOKDALE ELK GROVEFACILITY NUMBER:
347005512
ADMINISTRATOR:JERICA HOWARDFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108; 108CENSUS: 47DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director Carrie Baker TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Facility did not ensure resident's room was clean
Staff did not ensure resident had a clean mattress
INVESTIGATION FINDINGS:
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LPA Jason Lund arrived at the above facility to deliver findings on the above allegations. LPA Lund met with Executive Director Carrie Baker and explained the reason for the visit. The current census is 47.

During the course of the investigation, LPA conducted interviews with staff and witness. LPA reviewed facility reports and other documents.

The investigation revealed that resident (R1) was admitted at the facility for approximately a month. When R1 moved into the facility R1 was moved into room E13. The room had some type of water damage to the wall. The bathroom towel rack was damaged and not replaced when damaged. On 6/29/2021 when LPA Lund went to observe the room the facility was painting the room, but the damaged towel rack was still in the bathroom. Executive Director James Hall stated it would be replaced before a new resident would be moved in.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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
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
12/03/2020 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20201203112652

FACILITY NAME:BROOKDALE ELK GROVEFACILITY NUMBER:
347005512
ADMINISTRATOR:JERICA HOWARDFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108; 108CENSUS: 47DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director Carrie Baker TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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3
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5
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9
Staff did not meet residents hygiene needs
Resident left in soiled diaper for an extended period of time
Staff did not ensure resident had a mattress pad/bottom fitted sheet
INVESTIGATION FINDINGS:
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Based on interviews, review of records, R-1 LIC 602A. R1 was bladder impairment (incontinent) and when family came to pick up R1 for visits R1 depends were full two of the five times that the family picked up R1 from the facility. R1 family didn’t visit R1 in the facility due to COVID 19 restrictions while R1 was at the facility. It was learned when R1 returned home after a approximately one month at the facility R1 didn’t have any type of rashes on R1 lower extremities.

Based on interviews, records review, R1 LIC 602A and other documents. R1 LIC 602A stated that R1 needed help with bathing, dressing and toileting needs. It was learned through interviews and records that R1 received hygiene needs while at the facility.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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 27-AS-20201203112652
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: 07/21/2021
NARRATIVE
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Based resident personal property the family stated that they gave the facility two mattress covers/pads for R1 bed. The resident personal property doesn’t have the mattress covers/pads on the inventory and the family didn’t take the mattress covers/pads back when R1 moved out because to damaged.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Executive Director Carrie Baker and a copy of report was left along with a copy of the appeal rights.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20201203112652
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: 07/21/2021
NARRATIVE
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It was learned through resident personal property records that R1 moved into the facility with a mattress provide from the family, LPA Lund received a copy of the receipt from the family. R1 LIC 602A states when R1 moved in, R1 was bladder impairment (incontinent). When R1 moved out of the facility approximately one month later the mattress was damaged from urine being leaked from R1. the family stated that they gave the facility two mattress covers/pads for R1 bed and the family failed to get the mattress covers/pads back when R1 moved out.

Based on a review of records and other documents the facility failed to ensure that R1 room was properly cleaned and room fixtures replaced before moving R1 into Room E13. R1 had bladder impairment (incontinent) and the facility staff failed to keep R1 bed and mattress from being damaged (Stained) from urine.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20201203112652
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: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited
CCR
87468(a)(2)
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87468(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Excutive Director will ensure that all rooms will be clean and safe residents. Will check off with maintence to confirm rooms are clean and safe before resident move in.
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Based on observation the licensee did not comply with the section cited above in LPA's observed that the bed had stains from urine from R1. Which poses a potential health, safety or personal rights risk to persons in care.
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Type B
08/04/2021
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Excutive Director assure that all residents have bed covers for residents.
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This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in LPA's observed that the room had damage to the wall and towel rack was damaged. Which poses a potential health, safety or personal rights risk to persons in care.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5