Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 07/20/2017
Date Signed 07/20/2017 02:29:06 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
10/05/2016 and conducted by Evaluator Brandon Haven
PUBLIC
COMPLAINT CONTROL NUMBER: 27-SC-20161005154454
FACILITY NAME:BROOKDALE ELK GROVEFACILITY NUMBER:
347005512
ADMINISTRATOR:BRENDA CHAPPELLFACILITY TYPE:
740
ADDRESS:6726 LAGUNA PARK DRIVETELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 84DATE:
07/20/2017
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Zachary Butcher - Executive DirectorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining multiple fractures and serious injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst Haven arrived at the facility and met with Zachary Butcher, Executive Director to deliver investigation findings. LPA and ED conducted a tour of the facility to ensure the health and safety of all residents present.

CCLD received a complaint on 10/5/2016, regarding the allegation of: Lack of supervision resulting in resident being injured. CCLD Investigative Bureau Investigator J. Thao conducted the investigation, which included interviewing pertinent parties and reviewing documentation. Investigator J. Thao found that on 7/26/2016, the resident (R1; see confidential names list) was assisted by staff (S1; see confidential names list) to the common area and was left unsupervised for approximately seventy (70) minutes. The resident was found by staff member (S1; see confidential names list) in another resident’s room. The resident had fallen out of their wheelchair. The resident sustained fractures to left femur as a result of the fall.

See 9099-C for continuation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Brandon HavenTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2017
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-SC-20161005154454

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: 07/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2017
Section Cited
87705(c)(4)
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Care of Persons with Dementia. Licensees who serve residents with dementia shall ensure an adequate number of direct care staff to support each resident’s needs.

Investigator J. Thao found that on 7/26/2016,
the resident was assisted by staff to the
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LPA and Facility Executive Director discussed the POC regarding the deficiency and agreed that the facility shall submit the DPO (Dementia Plan of Operation). Since the incident the facility has revised staffing and dementia care policy and proceedure. ED states DPO satisfies POC criteria. DPO to be submitted by: 8/4/2017
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common area and was left unsupervised for approx. seventy minutes. The resident was found by staff member in another resident’s room & the resident had fallen out of their wheelchair & sustained fractures to left femur as a result of the fall. (see 9099; 9099-C)
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During today’s facility inspection 7/20/2017, the facility has been advised that a under H&S Code §1569.49 the issuance of a Civil Penalty is currently under review and may be assessed at a later date, due to the resident sustaining serious bodily injury while in care of the facility.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Brandon HavenTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2017
LIC9099 (FAS) - (06/04)
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Control Number 27-SC-20161005154454
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: 07/20/2017
NARRATIVE
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The resident was a known fall risk and the facility had reported previous resident falls, via incident report, to CCLD on the following dates: 1/7/2015, 6/7/2016, 6/22/2016, and 7/26/2016.
As a result of this investigation, IB Investigator finds allegation to be (S) Substantiated – A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited, per Title 22 Regulations, Division 6 (See 9099-D):
    1. 87705(c)(4) Care of Persons with Dementia. Licensees who serve residents with dementia shall ensure an adequate number of direct care staff to support each resident’s needs.


During today’s facility inspection 7/20/2017, the facility has been advised that a under H&S Code §1569.49 the issuance of a Civil Penalty is currently under review and may be assessed at a later date, due to the resident sustaining serious bodily injury while in care of the facility.

Exit interview conducted. Appeal rights provided. Copy of report left at facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Brandon HavenTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2017
LIC9099 (FAS) - (06/04)
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