Inspection Reports for Brookdale Folsom

The inspection was an unannounced required annual inspection conducted by the Licensed Program Analyst to evaluate compliance with licensing requirements.

The facility was found to be clean, in good repair, and odor free with no deficiencies observed during the inspection. Resident files, medication documentation, staff files, and facility safety measures were reviewed and found to be compliant.

The visit was a case management visit regarding an Unusual Incident/Injury Report received by the Department on 2025-03-12 involving a resident who exited memory care and was found in the parking lot.

The resident was safely redirected back into the care home with no injuries observed. The facility reviewed and tested elopement policies and alarm doors, and conducted in-service training on elopement prevention and fire drills. No deficiencies were cited during the visit.

The visit was a case management inspection regarding an Unusual Incident/Injury Report and SOC341 received by the Department on 9/16/24 and 9/17/24, following allegations of physical abuse and sexual assault reported by a resident.

The facility conducted an internal investigation and found the allegations to be unsubstantiated as the accused staff was not present during the alleged incident. The resident was treated for a UTI and showed a change in cognition. No deficiencies were cited during the visit.

The complaint involved allegations by a resident of physical abuse and sexual assault by staff. The facility suspended the staff member pending investigation, which concluded the allegations were unsubstantiated. The resident refused further medical treatment initially but was later treated for a UTI. The facility reassessed the resident's condition and provided documentation to the Licensing Program Analyst.

An unannounced complaint investigation visit was conducted in response to an anonymous report alleging that a staff member provided care under the influence of drugs and alcohol.

The investigation included records review and extensive interviews with staff and residents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with no reports or documentation supporting the claim.

The complaint alleged that a staff member was under the influence of drugs and alcohol while working. The investigation found no evidence to substantiate this allegation, and the complaint was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-04-08 regarding allegations of inadequate care including leaving a resident in soiled briefs for extended periods, unmet care needs, and insufficient staff training.

The investigation substantiated the allegations that resident care needs were not met, including failure to keep the resident clean and dry, failure to provide personal care such as wearing compression socks and medication administration, and insufficient staff training on dementia care. Multiple interviews, hospice records, and observations supported these findings.

The complaint was substantiated based on evidence including staff interviews, hospice records, and observations. Allegations included leaving a resident (R1) in soiled briefs for extended periods, failure to meet care needs such as wearing compression socks and administering medication, and insufficient staff training. The resident was found to have dementia and exhibited combative behaviors complicating care. The facility failed to consistently provide care as required.

The inspection visit was conducted to follow up on an incident received by the Department on 2024-07-14 involving a resident found in distress in the courtyard.

The Licensing Program Analyst reviewed the resident's medical and care records, interviewed staff, and found that the resident has a routine of wandering. The facility has implemented alarms on courtyard doors to alert staff during excessive heat. No deficiencies were cited.

The visit was complaint-related following an incident where a resident with dementia was found sweating and having labored breathing in the courtyard. Staff reported hourly checks but could not recall the exact last sighting time. The complaint was investigated and no deficiencies were cited.

The inspection was conducted as a Required-1 Year Inspection to ensure compliance with Title 22 regulations during an unannounced visit.

The facility was found to be in compliance with no deficiencies cited. Observations included properly furnished apartments, sanitary bathrooms, safe food storage, and operational safety equipment.

The inspection was an unannounced Required-1 Year Inspection conducted by the Licensing Program Analyst to review resident and staff files and assess compliance with regulations.

No deficiencies were cited during this visit per California Code of Regulations, Title 22. The Licensing Program Analyst will return at a later time to complete the annual inspection.

The visit was an unannounced case management inspection conducted due to an incident report received by the Department on 2024-04-15 regarding a resident found outside the facility unassisted.

The facility was found deficient for failing to properly supervise resident R1, who was found AWOL outside the facility, posing an immediate health, safety, and personal rights risk. The deficiency was cited under California Code of Regulations, Title 22, Section 87464(f)(1).

The visit was triggered by a complaint/incident report received on 2024-04-15 concerning resident R1 found outside the facility unassisted. The complaint was substantiated by the finding of deficient supervision.

An unannounced complaint investigation was conducted due to an allegation that the facility mismanaged a resident's medications.

The investigation found discrepancies in medication counts for three residents, including medications over and under the documented amounts, and delays in receiving new prescriptions. The allegation was substantiated, and a deficiency was cited for failure to ensure residents received medications as prescribed, posing an immediate health and safety risk.

The complaint investigation was substantiated based on medication count and records reviewed. The allegation was that the facility mismanaged resident's medications.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-02-14 alleging that staff did not issue a resident a refund.

The Licensing Program Analyst reviewed staff and facility records, conducted interviews, and found that the facility met Title 22 requirements. The complaint was found to be unfounded and was dismissed.

The complaint alleging staff did not issue a resident a refund was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.

The visit was an unannounced case management follow-up regarding an SOC341 received by the Department on 2024-01-09 related to a resident allegation of rough treatment by staff.

The facility conducted an internal investigation and found no abuse by the staff member. The staff member was suspended and later terminated due to other performance issues. No deficiencies were cited during the visit.

The visit was an unannounced case management visit conducted regarding an SOC341 received by the Department on 2024-01-09.

During the visit, the Licensing Program Analyst conducted an interview and requested pertinent documentation. No deficiencies were cited.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-07-18 alleging inadequate supervision of residents resulting in one resident hitting another.

The investigation found no evidence that the facility was negligent or failed to adequately supervise residents. Staff were present during the incident and redirected residents immediately. The allegation was determined to be unsubstantiated due to insufficient evidence.

The complaint alleged that staff did not adequately supervise residents, resulting in a resident hitting another resident. The investigation included interviews and review of documentation such as physician reports, service plans, staff schedules, and a police report. The allegation was found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-01-17 alleging improper medication assistance, multiple falls, and staff leaving a resident unattended.

The investigation found all allegations to be unsubstantiated after reviewing medical records, interviewing staff and hospice nurse, and assessing facility procedures. No deficiencies were cited during the visit.

The complaint alleged that staff did not provide proper medication assistance to a resident, the resident sustained multiple falls, and staff left the resident unattended. The investigation included review of physician reports, medication administration records, incident reports, and interviews with six staff members, the Executive Director, and the hospice nurse. The findings concluded that the facility followed proper procedures, communicated with responsible parties and hospice, and implemented fall prevention plans. The Department found insufficient evidence to substantiate the allegations.

The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the health and safety conditions of the facility and ensure compliance with regulatory standards.

The Licensing Program Analyst toured the facility, reviewed resident and staff records, and found the facility to be in compliance with no deficiencies cited. Medications were properly stored and administered, and the facility was clean and well-maintained.

The visit was an unannounced Case Management - Health Checks inspection conducted to ensure the health and safety of residents in care.

The facility was toured including common areas, resident bedrooms, bathrooms, and kitchen. No immediate health, safety, or personal rights violations were observed, and the facility was found to be in substantial compliance with no deficiencies cited.

The inspection visit was an unannounced Case Management - Health Checks to ensure the health and safety of residents in care.

No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance at the time of the visit and no deficiencies were cited.

Unannounced complaint investigation visit conducted in response to allegations including failure to meet residents' showering needs and mismanagement of residents' medications.

The investigation found the allegation regarding showering needs to be unsubstantiated due to lack of evidence, and the medication mismanagement allegation was found to be unfounded after a medication audit and interviews. No deficiencies were cited.

The complaint investigation was triggered by allegations that facility staff failed to meet residents' showering needs and mismanaged residents' medications. The showering needs allegation was unsubstantiated, and the medication mismanagement allegation was unfounded.

Unannounced complaint investigation visit conducted in response to a complaint received on 2022-04-15 alleging staff did not distribute resident's self-administered medications as prescribed and staff did not observe resident for change in condition.

The investigation found that staff appeared to administer medications as prescribed, but there was unclear evidence regarding one resident's medication administration; the allegation was unsubstantiated. Regarding observation of resident condition changes, staff documentation and actions were appropriate, and the allegation was unfounded. No deficiencies were cited.

The complaint investigation was unannounced and involved review of medication documentation for 10 residents and interviews. The allegation that staff did not distribute medications as prescribed was found unsubstantiated due to lack of preponderance of evidence. The allegation that staff did not observe resident for change in condition was found unfounded based on documentation and hospital transfer.

Unannounced complaint investigation visit conducted in response to allegations received on 2022-05-24 regarding medication training, control drug counts, medication placement, and medication distribution practices at the facility.

All allegations were investigated and found to be unfounded, meaning the complaints were false, could not have happened, or were without reasonable basis. No deficiencies were cited based on the investigation.

The complaint included allegations that staff dispensing medications lacked proper medication training, control drug counts were inaccurate, medications were found on the floor and other inappropriate locations, and staff did not distribute residents' self-administered medications as prescribed. All allegations were found to be unfounded.

The inspection was an unannounced Required-1 Year Inspection conducted to assess infection control and overall health and safety compliance at the facility.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of this inspection.

Unannounced complaint investigation visit conducted in response to multiple allegations including resident injury, staff response times, facility response system disrepair, and staffing adequacy.

The investigation found all allegations to be unsubstantiated based on interviews, call button records, and staff schedules. While some residents reported delayed responses at times, there was insufficient evidence to prove neglect or inadequate staffing.

The complaint involved allegations that a resident sustained a fracture while in care, staff were not responding to call buttons timely, the facility's response system was in disrepair, and inadequate staffing to meet resident needs. All allegations were found to be unsubstantiated after investigation.

This was a case management visit to follow-up on a complaint investigation regarding physical abuse of a resident by facility staff, originally investigated in September 2021.

The Department substantiated that a staff member physically abused a resident, violating residents' personal rights. A civil penalty of $9,500 was issued for the physical abuse violation.

The complaint investigation substantiated that a facility staff (S1) physically abused a resident (R1) as evidenced by video surveillance showing slapping, hair pulling, and rough handling. The complaint was received on September 7, 2021, and completed on September 10, 2021.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-09-10 regarding resident care and staffing issues at Brookdale Folsom facility.

The investigation found two allegations unsubstantiated: that a resident was left unattended on the floor after a fall and that the facility did not have sufficient staff to meet residents' needs. One allegation, that a resident was not treated with dignity due to rough treatment by staff, was substantiated, resulting in staff removal, training, and a citation.

The complaint investigation addressed three main allegations: 1) Resident left unattended on floor after fall, 2) Insufficient staffing to meet resident needs, and 3) Resident not treated with dignity. The first two allegations were found unsubstantiated after interviews, video review, and documentation. The third allegation was substantiated based on video evidence and staff interviews, leading to staff removal and facility citation.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-11-03 regarding timely access to resident records and signed admission agreements.

The investigation found two allegations unfounded: staff did not make resident records available in a timely manner and the facility did not have a signed admission agreement. One allegation was substantiated: resident records were incomplete as the facility did not provide all resident documents to the responsible party.

The complaint investigation was initiated due to allegations that staff did not make resident records available timely, the facility lacked a signed admission agreement, and resident records were incomplete. The first two allegations were found unfounded after interviews and document review. The third allegation was substantiated as the facility failed to provide all resident documents to the responsible party on September 23, 2021.

The visit was an unannounced case management inspection to issue citations and assess civil penalties related to staffing and abuse complaints. It included substantiated complaint allegations of staff abuse and failure to report abuse.

The facility allowed a staff member to work without criminal record clearance, posing an immediate health and safety risk. Additionally, substantiated complaints found staff physically abused a resident and another staff member failed to report the abuse as mandated. Civil penalties were assessed.

On 09/10/2021, the Department substantiated complaint allegations that staff hit a resident, pulled a resident's hair, and mistreated a resident. Another staff member observed the abuse but failed to report it as required for a mandated reporter. Civil penalties of $500 were assessed for a resident sustaining serious bodily injury.

The visit was an unannounced Case Management visit to deliver an Order to Individual of Immediate Exclusion and an Order to Licensee/Facility of Immediate Exclusion due to prior employees not allowed to work or be present in the facility.

The Licensing Program Analysts delivered notice of Immediate Exclusion to the Administrator, explaining that prior employees Sharan Kaur and Kandice Taylor are prohibited from working, being present, or having contact with clients in any licensed residential or child day care facility.

Unannounced complaint investigation visit triggered by allegations of staff hitting, pulling hair, and mistreating a resident while in care.

Investigation substantiated the allegations based on surveillance video showing staff hitting and pulling a resident's hair, rough handling, and inappropriate actions. Staff involved were removed and training was conducted for all staff on abuse, neglect, and mandatory reporting.

Complaint was substantiated based on evidence including surveillance video. Allegations included staff hitting a resident, pulling hair, and mistreatment. Staff involved were removed and authorities notified.

The inspection was an unannounced Required-1 Year Inspection conducted to assess infection control compliance and overall health and safety of residents at the facility.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

The visit was conducted as a case management visit to address a deficiency discovered during a complaint investigation regarding a resident being denied access to a phone.

The investigation found that a resident's personal cell phone was confiscated due to repeated loss and disruptive calling behavior, but no reassessment or needs and services plan was created to address the issue, resulting in a cited deficiency.

The complaint investigation was triggered by an allegation that a resident was denied access to a phone (Complaint Control Number 27-AS-20201007154720).

The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 11/19/2020 regarding resident care, notification of representatives, supervision, and safeguarding of personal belongings at Brookdale Folsom facility.

The investigation found one allegation substantiated regarding failure to provide timely written notice of rate increase to the resident's authorized representative. Another allegation of lack of supervision resulting in resident injury was substantiated with deficiencies cited. Other allegations, including failure to notify representative of change in level of care and failure to safeguard personal belongings, were found to be unfounded or unsubstantiated. Deficiencies related to staffing and notification were cited with Type A and Type B severity.

The complaint investigation was triggered by allegations including failure to notify authorized representative of change in level of care, lack of supervision causing resident assault and injury, failure to provide timely written notice of rate increase, and failure to safeguard resident's personal belongings. The allegation of failure to notify representative of change in level of care was found unfounded. The lack of supervision and failure to provide timely written notice were substantiated. The failure to safeguard belongings was unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2020-10-07 regarding resident injuries from a fall, safeguarding of resident belongings, and denial of phone access.

The investigation found insufficient evidence to substantiate the allegations of a fall caused by facility hazards, failure to safeguard resident belongings, and denial of phone access. The allegations were determined to be unsubstantiated or unfounded, and no deficiencies were cited.

The complaint involved allegations that a resident sustained injuries due to a fall caused by facility hazards, the facility did not safeguard resident belongings (a missing $1,500 MacBook laptop), and the resident was denied access to a phone. The investigation included interviews and document reviews. The fall was unwitnessed and no evidence supported a wet floor as cause. The missing laptop could not be conclusively linked to facility negligence. The phone was taken from the resident due to repeated loss and interference with daily functioning, but the resident had access to a facility phone. The allegations were found unsubstantiated or unfounded.

An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff did not keep a resident's room free from bugs.

The allegation was found to be unsubstantiated after review of documents, pest inspection reports, and staff interviews. The facility had removed the bug from the resident's room and retained ECO-Labs for ongoing bug control.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged abuse occurred.

The visit was a case management incident conducted via telephone regarding a Death Report (LIC 624A) received by Community Care Licensing on 04/10/2021.

No deficiencies were cited as a result of the case management visit. The facility reported that a resident was found unresponsive and pronounced dead due to cardiac arrest, and relevant documents were requested for review.