Inspection Report Summary
Most inspections in recent years found no deficiencies, including the most recent report dated September 23, 2025, which had no deficiencies cited. Several complaint investigations were unsubstantiated, showing that many concerns raised were not supported by evidence. However, the facility has a history of medication management issues and staffing shortages, with the most serious problems occurring between 2020 and mid-2024, including immediate health and safety risks related to medication errors and inadequate supervision of residents with dementia. Since then, the facility appears to have improved, with no deficiencies noted in annual inspections from 2024 onward and no recent enforcement actions or fines listed. Minor or isolated issues have been addressed, and recent reports indicate better compliance with care and safety standards.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 47
Capacity: 56
Deficiencies: 0
Sep 23, 2025
Visit Reason
The visit was an unannounced case management visit conducted due to multiple incident reports concerning Resident #1 sent by the facility to Community Care Licensing.
Findings
The Licensing Program Analyst conducted interviews and reviewed relevant documents related to the incidents. No deficiencies were cited at this time.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during the case management visit. |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 39
Capacity: 56
Deficiencies: 0
Apr 3, 2025
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, safe, sanitary, and in good condition with no observed violations of health, safety, or personal rights. Staff files and resident files were reviewed and found to be in compliance with training and clearance requirements. No deficiencies were observed during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during inspection and named in the report. |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 56
Deficiencies: 0
Feb 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-05-16 regarding medication administration, care and supervision, food safety, and other concerns at the facility.
Findings
The investigation found all allegations to be unsubstantiated or unfounded after reviewing documentation, conducting interviews, and performing audits. No evidence was found to prove violations related to medication administration, resident care, food safety, or pest control.
Complaint Details
The complaint investigation addressed multiple allegations including improper medication administration, lack of care and supervision resulting in falls and pressure injuries, food preparation safety violations, serving expired food, rough handling of residents, failure to provide incontinence care products, and pest issues. All allegations were found to be unsubstantiated or unfounded based on evidence and interviews.
Report Facts
Complaint Control Number: 59
Medication audit residents: 3
Post Fall Evaluations reviewed: 6
Unusual Incident Reports reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst and Manager during investigation; involved in interviews related to findings |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted complaint investigation, medication audit, interviews, and report preparation |
| Laura Munoz | Licensing Program Manager | Arrived at facility to deliver final findings and participated in investigation |
| Staff #1 | Interviewed regarding allegation of rough handling of resident |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 0
Sep 12, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2024-06-18 regarding a resident sustaining unexplained bruising while in care.
Findings
The investigation included interviews and document reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred. Staff and residents did not express concerns about abuse or safety.
Complaint Details
Allegation: Resident sustained unexplained bruising while in care. The mark was observed on 06/18/24 but was no longer present by 9:00 AM that day. Interviews indicated the resident has a history of self-inflicted slapping and no evidence of staff abuse was found. The complaint was unsubstantiated.
Report Facts
Facility capacity: 56
Census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jerilyn Purol | Administrator / Executive Director | Met with Licensing Program Analyst during investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 1
May 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-02-26 alleging that staff did not dispense residents' medications as prescribed.
Findings
The investigation substantiated that the facility did not ensure residents were given their medications as prescribed, based on medication audits revealing multiple discrepancies for three residents. Two other allegations regarding bathing and prevention of resident-to-resident hitting were found unsubstantiated.
Complaint Details
The complaint alleged that staff did not dispense residents' medications as prescribed. This allegation was substantiated based on medication audits and documentation review. Two other allegations—failure to ensure residents were bathed regularly and failure to prevent resident-to-resident hitting—were investigated and found unsubstantiated.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that residents were given their medications as prescribed, posing an immediate health and safety risk. |
Report Facts
Residents reviewed in medication audit: 5
Residents with medication discrepancies: 3
Facility capacity: 56
Current census: 33
Plan of Correction due date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during the investigation and named in findings related to medication discrepancies. |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the complaint investigation and medication audit. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 0
May 2, 2024
Visit Reason
The visit was conducted to gather additional information regarding an unusual incident/injury report involving alleged use of force by a staff member to redirect a resident from another resident's room.
Findings
During the visit, the Licensing Program Analyst and Executive Director discussed the incident and the facility's internal investigation. The resident involved has since moved to a higher level of care. No deficiencies were cited at this time.
Complaint Details
The visit was triggered by a complaint related to an incident reported on 04/25/2024 involving alleged use of force by Staff #1. The complaint was investigated internally by the facility and discussed with the Licensing Program Analyst. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst to discuss the incident during the visit. |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the unannounced Case Management Incident visit. |
Inspection Report
Annual Inspection
Census: 35
Capacity: 56
Deficiencies: 0
Mar 20, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The inspection found the facility to be in good condition with no deficiencies cited. Areas toured included resident rooms, common areas, and safety features were verified. Staff files and resident records were reviewed and found compliant.
Report Facts
Personnel files reviewed: 8
Resident files reviewed: 8
Facility capacity: 56
Resident census: 35
Resident rooms toured: 10
Common shower rooms toured: 3
Hot water temperature: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the inspection and authored the report |
| Laura Munoz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 56
Deficiencies: 0
Dec 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff forced a resident to eat while in care.
Findings
After extensive interviews with the Executive Director, staff, and residents, the allegation was found to be unfounded, meaning it was false, could not have happened, or was without a reasonable basis.
Complaint Details
Allegation: Staff force resident to eat while in care. The investigation included interviews with the Executive Director, four staff members, and seven residents. It was found that residents are self-fed or assisted privately as needed, and no force feeding was observed or reported.
Report Facts
Capacity: 56
Census: 32
Staff interviewed: 4
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analysts and provided information during the investigation |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 56
Deficiencies: 0
Nov 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-14 alleging insufficient staffing, inadequate staff training, and failure to provide resident records to an authorized representative.
Findings
The investigation found all allegations to be unsubstantiated. Staff were found to meet training requirements and provide adequate care to residents, including assistance with activities of daily living. The facility did not provide all incident reports to the resident's authorized representative, but these reports were deemed internal documents and not part of resident records.
Complaint Details
The complaint included allegations that the facility did not have enough staff to meet residents' needs, staff were inadequately trained, and staff did not provide all resident records to the authorized representative. All allegations were found unsubstantiated after review of staff interviews, training records, physician reports, and communication with the resident's responsible party.
Report Facts
Facility capacity: 56
Census: 32
Number of facility staff interviewed: 5
Number of caregivers per shift: 3
Number of Med Techs per shift: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during investigation and provided statements regarding incident reports |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Ayana Allison | Health and Wellness Director | Provided statements and email communications regarding resident incident reports |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 56
Deficiencies: 0
Sep 28, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-04-10 alleging that a resident in care sustained unexplained injuries.
Findings
The investigation found that the resident (R1) had multiple abrasions and injuries with no documented falls at the facility. Staff were unable to explain how the injuries occurred. After reviewing medical reports and interviewing staff, the Department found no evidence of negligence by the facility. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained unexplained injuries. The investigation included interviews with eight staff members and review of resident medical and care documents. The fall was unwitnessed and the facility was unsure when it occurred. The resident was not sent to the hospital but was evaluated by a nurse practitioner who ordered an X-ray. The complaint was found to be unsubstantiated.
Report Facts
Facility capacity: 56
Resident census: 29
Staff interviewed: 8
Staff statements indicating observed injuries: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Ayana Allison | Health and Wellness Director | Provided interview statement regarding timing of resident's fall |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 56
Deficiencies: 0
Apr 19, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 02/28/2023 alleging that staff hit a resident.
Findings
The investigation included interviews with staff and review of relevant documents. The allegation that staff hit a resident was found to be unsubstantiated due to lack of preponderance of evidence, despite some staff statements indicating an admission. The facility conducted an internal investigation and terminated the involved staff.
Complaint Details
The complaint alleged that staff hit a resident. Interviews revealed conflicting statements, with one staff denying the incident and others overhearing an admission. No physical injuries were observed on the resident. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 56
Census: 29
Number of staff interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 30
Capacity: 56
Deficiencies: 0
Apr 5, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to ensure the health and safety of residents in care at the facility.
Findings
The inspection found the facility to be in compliance with no deficiencies cited. Areas toured and reviewed included resident apartments, common areas, staff and resident files, medication storage, and safety equipment. All observed conditions met regulatory requirements.
Report Facts
Residents apartments toured: 9
Staff files reviewed: 3
Resident files reviewed: 5
Residents medications reviewed: 5
Hot water temperature: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analysts during inspection and involved in facility tour and document submission |
| Sarena Keosavang | Licensing Program Analyst | Conducted inspection and signed report |
| Sarah Benson | Licensing Program Analyst | Conducted inspection |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 56
Deficiencies: 0
Apr 5, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-02-03 alleging wrongful eviction of a resident.
Findings
The investigation found that although the allegation of wrongful eviction may have occurred, there was insufficient evidence to substantiate the claim. The facility worked with the resident's responsible party to allow additional time for relocation, and the resident moved out on 2023-02-11.
Complaint Details
The complaint alleged wrongful eviction of resident R1. The investigation revealed that R1's responsible party had submitted a 30-day notice, but later requested to stop it. The facility initially insisted on removal by 02/04/2023 but agreed to extend relocation time until 02/10/2023. The facility did not submit a 30-day notice to the Department and worked with the responsible party. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 56
Census: 30
Complaint received date: Feb 3, 2023
Resident relocation deadline: Feb 4, 2023
Resident relocation extended date: Feb 10, 2023
Resident moved out date: Feb 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analysts during investigation and provided interview statements |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Routine
Census: 37
Capacity: 56
Deficiencies: 0
Oct 27, 2022
Visit Reason
Unannounced Case Management COVID-19 infection control inspection conducted to assess the facility's implementation of COVID-19 infection control policies and procedures.
Findings
The inspection found that COVID-19 infection control policies were implemented, including signage, visitor screening, and adequate PPE supplies and staffing. Recommendations were made for fit testing, vital sign monitoring, staff training, hand hygiene, cleaning supplies calibration, and food service protocols. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn Purol | Executive Director | Met with Licensing Program Analyst during inspection and confirmed COVID-19 cases. |
| Ayana Allison | Wellness Director | Confirmed positive COVID-19 cases at the facility. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection. |
| Cherish Mendoza | CDPH HAI | Participated in the inspection. |
| Rania Alnubani | Sacramento County Public Health Registered Nurse | Participated in the inspection. |
Inspection Report
Follow-Up
Census: 32
Capacity: 56
Deficiencies: 1
Aug 5, 2022
Visit Reason
The visit was conducted as a case management follow-up on an Unusual Incident/Injury Report received by the Department regarding residents who left the premises unassisted.
Findings
The facility failed to properly supervise six residents with dementia who left the premises, posing an immediate health, safety, and personal rights risk. A deficiency was cited for inadequate care and supervision of residents with dementia.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure that residents R1, R2, R3, R4, R5, and R6 were properly supervised, resulting in the AWOL of all 6 residents, posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Residents involved in AWOL incident: 6
Deficiency Plan of Correction due date: Aug 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Young | Executive Director | Met with Licensing Program Analyst during case management visit and involved in staff training following incident. |
| Michael Hood | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Anthony Perez | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 24
Capacity: 56
Deficiencies: 0
Apr 29, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate infection control and ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed during the facility tour. No deficiencies were cited in the infection control domain.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Young | Executive Director | Met with Licensing Program Analyst during inspection and completed infection control domain. |
| Michael Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control evaluation. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 16
Capacity: 56
Deficiencies: 0
Oct 1, 2021
Visit Reason
A follow-up meeting to a non-compliance conference was conducted to address the facility's compliance following a previous non-compliance conference held on 7/15/2021 due to multiple citations and substantiated complaints.
Findings
The facility is making efforts to achieve continued and substantial compliance by implementing plans to address fall risks, conducting regular staff training including medication technicians, and performing regular audits of residents' medications.
Complaint Details
The follow-up was related to a previous non-compliance conference triggered by 4 Type A citations and 12 substantiated complaint allegations since 2018.
Report Facts
Type A citations: 4
substantiated complaint allegations: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Sallee | Administrator/Executive Director | Facility staff present during the follow-up meeting |
| Laura Fischer | Vice President of Operations | Facility staff present during the follow-up meeting |
| Zachary Butcher | District Director of Operations | Facility staff present during the follow-up meeting |
| Laura Eckert | District Director of Operations | Facility staff present during the follow-up meeting |
| Rhonda Dolcater | Compliance Specialist | Facility staff present during the follow-up meeting |
| Jina Amstutz | Compliance Specialist | Facility staff present during the follow-up meeting |
| Joel S. Goldman | Attorney | Facility staff present during the follow-up meeting |
| Rayna Bryson | Licensing Program Manager | CCLD staff present during the follow-up meeting |
| Michael Hood | Licensing Program Analyst | CCLD staff present during the follow-up meeting |
Inspection Report
Capacity: 56
Deficiencies: 2
Jul 15, 2021
Visit Reason
The visit was a Case Management - Legal/Non-compliance conference conducted to address ongoing non-compliance issues at the facility, including multiple Type A citations and substantiated complaint allegations since 2018.
Findings
The facility has a history of 14 Type A citations and 12 substantiated complaint allegations since 2018, with repeat violations related to medication errors and shortages of trained and qualified staff. The facility committed to actions to achieve continued compliance, including regular medication audits and maintaining updated staff training records.
Complaint Details
The facility had 12 substantiated complaint allegations since 2018.
Severity Breakdown
Type A: 14
Deficiencies (2)
| Description | Severity |
|---|---|
| Repeat violations regarding medication errors - medication management | Type A |
| Shortages of trained and qualified staff - basic services and staffing | — |
Report Facts
Type A citations: 14
Substantiated complaint allegations: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Salle | Administrator/Executive Director | Facility staff present during the non-compliance conference |
| Laura Fischer | Vice President of Operations | Facility staff present during the non-compliance conference |
| Rhonda Dolcater | District Director of Operations | Facility staff present during the non-compliance conference |
| Lori Fries | District Director of Clinical Services | Facility staff present during the non-compliance conference |
| Jina Amstutz | Compliance Specialist | Facility staff present during the non-compliance conference |
| Joel S. Goldman | Attorney | Facility staff present during the non-compliance conference |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 56
Deficiencies: 1
Jul 2, 2021
Visit Reason
The visit was a case management incident investigation to discuss Incident Reports submitted for 5/12/2021 and 5/19/2021 regarding medication errors.
Findings
Two medication errors were identified: resident R1 received the wrong medication on 5/12/2021, and resident R2 received an incorrect dosage on 5/19/2021. Both incidents were corrected, residents monitored with no adverse reactions, and staff received additional medication management training. A civil penalty was issued due to repeated citation of the regulation within 12 months.
Complaint Details
The visit was complaint-related, investigating medication errors reported in incident reports for 5/12/2021 and 5/19/2021. The complaint was substantiated as deficiencies were cited and a civil penalty issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, resulting in medication errors for residents R1 and R2. | Type A |
Report Facts
Capacity: 56
Census: 19
Incident dates: 2
Plan of Correction due date: Jul 6, 2021
Repeated citations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Troy Ordonez | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
| Christine Sallee | Executive Director | Met with Licensing Program Analyst during the visit and interviewed regarding incidents |
Inspection Report
Follow-Up
Census: 19
Capacity: 56
Deficiencies: 0
Jul 2, 2021
Visit Reason
The visit was a case management follow-up on an Incident Report dated 5/14/2021 involving a resident who left the facility unaccompanied.
Findings
The facility responded appropriately to the incident by monitoring the resident, providing staff training on elopement, conducting regular elopement drills, routing the back gate alarm to staff pagers, and initiating regular gate checks. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by an incident report regarding a resident who left the facility and was found at a nearby store. The incident was investigated and found to be managed properly with no adverse effects to the resident.
Report Facts
Incident monitoring period: 72
Facility capacity: 56
Resident census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Tryon | Licensing Program Analyst | Conducted the case management visit and investigation |
| Christine Sallee | Executive Director | Spoke with Licensing Program Analyst regarding the incident |
Inspection Report
Annual Inspection
Census: 18
Capacity: 56
Deficiencies: 0
May 25, 2021
Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed, and no deficiencies were cited as a result of the inspection.
Inspection Report
Complaint Investigation
Census: 20
Capacity: 56
Deficiencies: 3
Apr 19, 2021
Visit Reason
The visit was a case management inspection focused on deficiencies, including investigation of complaint control number 27-AS-20200928100545 from 9/29/20 to 4/16/21, and additional findings related to failure to report suspected dependent abuse and failure to provide timely assistance to residents.
Findings
The investigation found failures to report suspected dependent abuse incidents timely, inadequate assistance with bathing, dressing, eating, and incontinence care for residents, and failure by the administrator to provide proper medication management, staffing, record maintenance, incident reporting, and staff supervision. These deficiencies posed immediate risks to residents and included repeat citations.
Complaint Details
Investigation of complaint control number 27-AS-20200928100545 from 9/29/20 to 4/16/21 found violations including failure to report suspected dependent abuse and inadequate resident care.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report suspected dependent abuse incidents timely as required by Welfare and Institutions Code Section 15630(b)(1). | Type B |
| Failure to provide timely assistance with bathing, dressing, eating, and incontinence care as agreed in care plans, resulting in residents not kept clean and dry and facility odors. | Type A |
| Administrator failed to provide necessary support and resources for proper medication management, adequate staffing, resident records maintenance, incident reporting, and staff screening and supervision. | Type A |
Report Facts
Capacity: 56
Census: 20
Plan of Correction Due Date: May 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Scarberry | Administrator | Named in findings related to failure to provide necessary support and resources |
| Sumit Benipal | Wellness Director | Presented information about failure to report suspected dependent abuse |
| Kevin Mknelly | Licensing Program Analyst | Conducted inspection and authored report |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 56
Deficiencies: 3
Apr 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-11-16 regarding allegations of staff failing to protect resident's personal property from theft, failure to seek timely medical care, and overcharging residents for services.
Findings
The investigation substantiated the allegations that staff failed to protect a resident's personal property resulting in theft of a credit card used fraudulently for approximately $2400, failed to arrange timely podiatry care for a resident causing pain, and overcharged a resident contrary to the admission agreement. These deficiencies posed immediate and potential risks to residents' personal rights and health and safety.
Complaint Details
The complaint was substantiated based on evidence including resident and facility records, police reports, and interviews. The complaint control number is 27-AS-20201116134611. The allegations involved theft of resident property, failure to seek timely medical care, and overcharging. The Licensing Program Analyst found the allegations valid and posed immediate and potential risks to residents.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect resident from neglect and financial exploitation as staff allowed unsupervised access resulting in theft of resident's credit card. | Type A |
| Failure to arrange or assist in arranging timely medical and dental care for resident's overgrown toenails causing pain. | Type A |
| Failure to comply with admission agreement payment provisions resulting in overcharging resident for services. | Type B |
Report Facts
Credit card fraud amount: 2400
Facility capacity: 56
Resident census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Scarberry | Administrator | Named in findings related to awareness of overbilling and failure to correct it |
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation report |
| Sumit Benipal | Wellness Director | Acknowledged resident's need for podiatry care and scheduling issues |
| Sharon Monck | Facility representative met during inspection |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 56
Deficiencies: 5
Apr 19, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including staff mismanaging medication, unmet hygienic care needs, incomplete resident records, lack of activities, and inadequate staffing.
Findings
The investigation substantiated multiple allegations including medication errors, insufficient staffing leading to unmet resident care needs, incomplete resident records, and lack of planned activities. One allegation regarding staff falsifying medical records was unsubstantiated, and another regarding residents sustaining multiple fractures due to falls was unfounded with only one fracture confirmed.
Complaint Details
The complaint investigation was substantiated for allegations of medication mismanagement, unmet hygienic care needs, incomplete records, lack of activities, and inadequate staffing. The allegation of staff falsifying medical records was unsubstantiated. The allegation of residents sustaining multiple fractures due to falls was unfounded except for one confirmed fracture.
Severity Breakdown
Type A: 3
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| The licensee failed to assist residents with self-administered medications as needed, evidenced by a resident not receiving prescribed medication, posing an immediate risk. This was a repeat violation within 12 months. | Type A |
| Basic services including personal assistance with activities of daily living such as dressing, eating, bathing, and medication assistance were not adequately provided due to staff shortages, posing an immediate risk to residents. | Type A |
| Facility personnel were insufficient in number and competence to meet resident needs, posing an immediate risk to residents. | Type A |
| An activities director was not present at the facility from September 2020 to March 2021, resulting in inadequate planned activities, posing a potential risk to residents. | Type B |
| Annual medical assessments for residents with dementia were expired for five of eight records reviewed, posing a potential risk to residents. | Type B |
Report Facts
Facility capacity: 56
Resident census: 20
Medication error incident date: Oct 9, 2020
Fall incident date: Sep 22, 2020
Plan of Correction due dates: May 5, 2021
Plan of Correction due dates: Apr 26, 2021
Plan of Correction due dates: Apr 21, 2021
Plan of Correction due dates: May 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
| Jennifer Scarberry | Administrator | Facility administrator during investigation |
| Sharon Monck | Operations Specialist and Acting Administrator | Met with LPA during investigation |
| Lori Fries | District Director of Clinical Services | Interviewed regarding medication errors |
| Sumit Benipal | Wellness Director | Reported staffing and incident information |
Inspection Report
Follow-Up
Census: 19
Capacity: 56
Deficiencies: 1
Apr 14, 2021
Visit Reason
The visit was a case management follow-up on three incident reports received by the Department related to medication administration issues.
Findings
The inspection found multiple medication errors including missed administration of fentanyl patches and Norco, missing medication in the cart, and lack of communication with hospice regarding medication reorders. Deficiencies were cited related to medication errors posing immediate health and safety risks.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure residents are receiving medications as prescribed, posing immediate health, safety, and personal rights risks. | Type A |
Report Facts
Census: 19
Total Capacity: 56
Deficiency Count: 1
Plan of Correction Due Date: Apr 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Scarberry | Administrator | Named as facility administrator |
| Sharon Monck | Acting Administrator | Met with Licensing Program Analysts during inspection |
| Michael Hood | Licensing Program Analyst | Conducted inspection and authored report |
| Anthony Perez | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Census: 27
Capacity: 56
Deficiencies: 0
Nov 16, 2020
Visit Reason
The visit was a case management visit conducted to deliver an Order to Individual of Immediate Exclusion from all facilities and an Order to Licensee/Facility of Immediate Exclusion from Facility.
Findings
The Licensing Program Analyst delivered an exclusion order to the facility administrator for a staff member who is excluded from the facility due to reasons unrelated to this facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Scarberry | Administrator | Met with Licensing Program Analyst during the visit and received the exclusion order. |
| Bethany Huusfeldt | Licensing Program Analyst | Conducted the case management visit and delivered the exclusion order. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 56
Deficiencies: 3
Nov 10, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-03 regarding alleged deficiencies in care and supervision at Brookdale Citrus Heights facility.
Findings
The investigation substantiated allegations that facility staff did not provide identified care and supervision, did not seek timely medical care for a resident, and violated resident personal rights. Specific deficiencies included delayed 9-1-1 response for a resident with chest pain, inadequate incontinent care, and improper administration and documentation of PRN medication without hospice approval. Another allegation of insufficient staffing was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff failed to provide identified care and supervision, failed to seek timely medical care, and violated resident personal rights. The allegation that the facility had insufficient staff was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to meet residents' personal rights to receive or reject medical care or other services, posing a potential risk to residents. | Type B |
| Failure to immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident's health, posing an immediate risk. | Type A |
| Failure to ensure incontinent residents are kept clean and dry and the facility remains free of odors from incontinence, posing a potential risk. | Type B |
Report Facts
Capacity: 56
Census: 27
Medication tablets prescribed: 10
Medication tablets remaining: 3
Medication tablets administered: 0.5
Plan of Correction due date: Nov 24, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Scarberry | Administrator | Facility administrator involved in the investigation and report signing |
| Maribeth Senty | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 56
Deficiencies: 2
Nov 10, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-22 alleging that facility staff mismanaged a resident's medication.
Findings
The investigation substantiated the complaint, finding that a resident was given a topical cream orally without a physician's order or consent, and medications were camouflaged or forced on residents. Medications were also found accessible to untrained staff and other residents, posing immediate risks to residents' health, safety, and personal rights.
Complaint Details
The complaint was substantiated based on evidence that staff mismanaged medication administration, including forcing medication and improper storage. The findings were supported by interviews and record reviews. The complaint control number is 27-AS-20200622151756.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care (a)(6)(D) - Assistance does not include forcing a resident to take medication, hiding or camouflaging medications, or infringing upon a resident's right to refuse. This requirement was not met as three residents were given medications camouflaged or forced. | Type A |
| Incidental Medical and Dental Care (h)(2) - Centrally stored medicines must be kept in a safe and locked place accessible only to responsible employees. This requirement was not met as medications were accessible to untrained staff and other residents. | Type B |
Report Facts
Capacity: 56
Census: 27
Plan of Correction Due Date: Nov 24, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Scarberry | Administrator | Named in medication error finding and interviewed during investigation |
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation report |
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