347005512-8-31-2021-27-AS-KHOS-C6FH9W-20210901060036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 08/30/2021
Date Signed: 08/31/2021 09:41:45 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
01/14/2021 and conducted by Evaluator Charlie Yang

COMPLAINT CONTROL NUMBER: 27-AS-20210114143054

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: 46	DATE:	08/30/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Susie Sarria		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care

Resident is malnourished

Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility and was met by facility representative Susie Sarria by LPA Charlie Yang on 08/30/2021. The purpose of this visit was to complete and deliver findings for this complaint unto this facility and its representative.
Current census was 46 residents.
Based on interviews and a review of the documents gathered during the course of this investigation, it was observed that resident, R1, was sent to the hospital via ambulance on 01/11/2021 and admitted that same day. The resident was eventually discharged on 01/13/2021 back to this facility on that same date.
Based on a review of the medical records obtained, it was observed that R1 had a history of malnutrition and lesions. These symptoms were attributed to inadequate oral intake due to dysphagia and COVID 19 which R1 was diagnosed with upon admission. It was also learned that these symptoms could result in R1 having a poor appetite.
In addition, records indicated that upon examination by the medical staff on 01/12/2021 it was observed that R1 did have redness and a scab on her left forearm and elbow. Other observations included discoloration

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

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-20210114143054

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: 08/30/2021

NARRATIVE

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of other parts of R1's body but that these bruises were not staged. It was further noted in the medical records that medical staff did not believe that R1 was under any distress at any time while under evaluation. R1 was diagnosed as being a fall risk and a risk assessment plan was advised upon discharge back to this facility by medical staff.

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

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC9099 (FAS) - (06/04)

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