Inspection Reports for Brunswick Village Assisted Living

CA, 95945

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Inspection Report Summary

Most inspections found no deficiencies, including the most recent annual inspection on June 5, 2025, which was clean. Some complaint investigations were unsubstantiated, such as allegations about scabies, staff intoxication, food service, and resident care. However, a few deficiencies were noted in earlier reports, primarily related to staff training on colostomy and catheter care, failure to report an outbreak in 2021, and incomplete notification to residents’ representatives after incidents. These issues were isolated and did not result in fines or enforcement actions, and the facility showed improvement with no deficiencies found in the latest inspections. Overall, the facility appears to be maintaining compliance with regulatory requirements over time.

Deficiencies per Year

4 3 2 1 0
2021
2022
2023
2024
2025
Moderate

Census Over Time

40 60 80 100 120 May '21 Jul '21 Jun '22 Apr '24 May '24 May '25
Census Capacity
Inspection Report Annual Inspection Capacity: 100 Deficiencies: 0 Jun 5, 2025
Visit Reason
This was an unannounced annual inspection visit conducted as a required one-year inspection.
Findings
The inspection included a tour of the facility, review of resident and staff training records, and discussions on several topics. No deficiencies were cited during this visit.
Report Facts
Number of bedrooms: 56 Memory care unit rooms: 12
Employees Mentioned
NameTitleContext
Kristie LaineExecutive DirectorMet with during the inspection and finished the tour.
Clayton FowlerMaintenance DirectorToured the facility with the Licensing Program Analyst.
Kerry HiratsukaLicensing Program AnalystConducted the unannounced annual visit.
Troy OrdonezLicensing Program ManagerNamed as Licensing Program Manager on the report.
Inspection Report Complaint Investigation Census: 59 Capacity: 100 Deficiencies: 0 May 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent an outbreak of scabies.
Findings
The investigation found that one resident was being treated for a non-contagious skin issue and no residents or staff had developed any rashes or contagious diseases. The allegation was concluded to be unfounded.
Complaint Details
The complaint alleged that staff did not prevent an outbreak of scabies. The investigation concluded the allegation was unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 100 Census: 59
Employees Mentioned
NameTitleContext
Kerry HiratsukaEvaluatorConducted the complaint investigation
Kristie LaineAdministratorFacility administrator met during the investigation
Inspection Report Complaint Investigation Census: 58 Capacity: 100 Deficiencies: 1 May 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not adequately trained to meet residents' needs and that staff were intoxicated while working with residents.
Findings
The allegation regarding inadequate staff training was substantiated due to lack of training on colostomy care and incomplete training on catheter care, posing a potential health and safety risk. The allegation that staff were intoxicated while working was found to be unfounded with no staff observed working intoxicated.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not adequately trained to meet residents' needs, specifically regarding colostomy and catheter care. The allegation that staff were intoxicated while working was found to be unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
DescriptionSeverity
Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This requirement not met as evidence by the facility based on review of training logs the staff didn't have training prior to taking care of residents with colostomy bag and catheter which poses a potential health and safety risk to resident in care.Type B
Report Facts
Capacity: 100 Census: 58 Deficiencies cited: 1 Plan of Correction Due Date: May 30, 2025
Employees Mentioned
NameTitleContext
Kerry HiratsukaLicensing Program AnalystConducted the complaint investigation and authored the report
Kristie LaineAdministratorFacility administrator interviewed during investigation
Troy OrdonezLicensing Program ManagerNamed in report as licensing program manager
Inspection Report Annual Inspection Census: 56 Capacity: 100 Deficiencies: 0 May 15, 2024
Visit Reason
This was an unannounced annual inspection visit required by the licensing authority to evaluate the facility's compliance with regulations.
Findings
The inspection included a tour of the facility, review of resident and staff training records, and discussion of administrative topics. No deficiencies were cited during this visit.
Report Facts
Bedrooms: 56 Memory care unit rooms: 12
Employees Mentioned
NameTitleContext
Kristie LaineAdministrator/DirectorMet with during the inspection
Clayton FowlerMaintenance DirectorToured the facility with the Licensing Program Analyst
Troy OrdonezLicensing Program ManagerNamed in the report header
Kerry HiratsukaLicensing Program AnalystConducted the unannounced annual visit
Inspection Report Complaint Investigation Census: 56 Capacity: 100 Deficiencies: 0 Apr 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-05 regarding inadequate food service, lack of dignity in staff treatment, and uncomfortable living environment for residents.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff, observations, and inspections did not confirm the complaints, resulting in an unsubstantiated finding.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations regarding food service, staff treatment, and living environment.
Report Facts
Capacity: 100 Census: 56
Employees Mentioned
NameTitleContext
Kristie LaineAdministratorFacility administrator involved in the investigation and referenced in findings
Kerry HiratsukaLicensing Program AnalystEvaluator who conducted the complaint investigation
Troy OrdonezLicensing Program ManagerManager overseeing the licensing program and report
Inspection Report Census: 56 Capacity: 100 Deficiencies: 1 Apr 25, 2024
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to investigate the licensee's change of the annual rate increase date without obtaining signed agreements from residents.
Findings
The licensee changed the date of the annual rate increase from the anniversary date to the beginning of the year without signed resident agreements for the change. Although the licensee gave the required 60-day notice for the fee increase, the signed modification for the date change was not obtained, constituting a deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
DescriptionSeverity
Failure to retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications related to the annual fee increase date change.Type B
Report Facts
Capacity: 100 Census: 56 Plan of Correction Due Date: May 25, 2024
Employees Mentioned
NameTitleContext
Kerry HiratsukaLicensing Program AnalystConducted the inspection and signed the report
Troy OrdonezLicensing Program ManagerSupervisor and Licensing Program Manager overseeing the inspection
Kristie LaineAdministrator/DirectorFacility Administrator met during inspection
Inspection Report Capacity: 100 Deficiencies: 0 Jan 11, 2024
Visit Reason
The visit was conducted to deliver an amended report for complaint #59-AS-20231109113548, originally delivered on 11/30/2023.
Findings
The findings of the complaint were determined to be unfounded and no deficiencies were cited during this visit.
Complaint Details
Complaint #59-AS-20231109113548 was investigated and found to be unfounded.
Inspection Report Complaint Investigation Capacity: 100 Deficiencies: 0 Nov 30, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff do not provide residents with activities, clean linen, or ensure resident rooms are kept clean.
Findings
The investigation found that residents were participating in activities, linens were being cleaned, and rooms were maintained clean with proper documentation for exceptions. All allegations were determined to be unfounded.
Complaint Details
The complaint investigation was unannounced and addressed three allegations: lack of activities, lack of clean linen, and unclean resident rooms. All allegations were found to be unfounded based on observations, interviews, and documentation.
Report Facts
Capacity: 100
Employees Mentioned
NameTitleContext
Kerry HiratsukaEvaluator / Licensing Program AnalystConducted the complaint investigation and authored the report
Kristie LaineAdministratorFacility administrator met during the investigation
Troy OrdonezLicensing Program ManagerNamed in report as Licensing Program Manager
Inspection Report Annual Inspection Census: 58 Capacity: 100 Deficiencies: 0 May 4, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with regulatory requirements for the facility.
Findings
The inspection found that all resident and staff files contained the required paperwork and training, the facility was compliant with fire drills, and no health or safety violations were observed during the tour of the facility. No deficiencies were cited.
Employees Mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the unannounced annual inspection and reviewed files and facility conditions.
Clayton FowlerSenior Building Services DirectorToured the facility with the Licensing Program Analyst to ensure health and safety of residents.
Inspection Report Annual Inspection Census: 50 Capacity: 100 Deficiencies: 0 Jun 16, 2022
Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection focusing on the infection control domain.
Findings
No deficiencies were cited during the inspection. The facility was toured and no immediate health, safety, or personal rights violations were observed.
Employees Mentioned
NameTitleContext
Clayton FowlerSenior Building Services DirectorMet with Licensing Program Analyst during inspection and authorized to sign report.
Kristie LaineAdministratorSpoke by phone with Licensing Program Analyst and authorized Senior Building Services Director to sign report.
Michael HoodLicensing Program AnalystConducted the Required-1 Year Inspection.
Anthony PerezLicensing Program ManagerNamed in report header.
Inspection Report Complaint Investigation Census: 53 Capacity: 100 Deficiencies: 1 Oct 15, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility failed to report an outbreak.
Findings
The investigation found that between August 27 and September 13, 2021, several residents and staff experienced symptoms of vomiting and/or diarrhea, which was not reported to Nevada County Public Health or Community Care Licensing as an outbreak. The allegation was substantiated.
Complaint Details
The complaint was substantiated based on evidence that the facility did not report a suspected outbreak to the appropriate authorities despite multiple residents and staff showing symptoms.
Severity Breakdown
Type B: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to notify Community Care Licensing and Nevada County Public Health of 7 residents with similar symptoms as a suspected outbreak within 24 hours as required.Type B
Report Facts
Residents symptomatic: 7 Staff symptomatic: 3 Deficiency due date: Oct 29, 2021
Employees Mentioned
NameTitleContext
Kristie LaineAdministratorInterviewed during investigation and acknowledged the failure to report the outbreak.
Melissa LusbyLicensing Program AnalystConducted the complaint investigation.
Anthony PerezLicensing Program ManagerOversaw the complaint investigation.
Inspection Report Complaint Investigation Capacity: 100 Deficiencies: 0 Aug 11, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not adhere to state anti-smoking laws at an assisted living facility.
Findings
The investigation concluded that the allegation was unfounded after interviews, policy reviews, and measurements of the smoking area distance from the main building.
Complaint Details
The complaint alleged non-adherence to state anti-smoking laws. The allegation was found to be unfounded, meaning it was false or without reasonable basis.
Employees Mentioned
NameTitleContext
Jacob WilliamsLicensing Program AnalystConducted the complaint investigation and exit interview.
Kristie LaineAdministratorFacility administrator met during the investigation.
Anthony PerezLicensing Program ManagerNamed as Licensing Program Manager on the report.
Inspection Report Complaint Investigation Census: 54 Capacity: 100 Deficiencies: 2 Jul 23, 2021
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that the facility did not follow doctor's orders and failed to notify the power of attorney regarding a resident's change of condition.
Findings
The investigation substantiated that the facility did not follow doctor's orders by failing to discontinue a pain medication as ordered and did not notify the responsible party immediately after a resident's unwitnessed fall. Another allegation of medication mismanagement was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that the facility did not follow doctor's orders and failed to notify the power of attorney regarding a resident's change of condition. Another allegation of medication mismanagement was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
DescriptionSeverity
Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by failure to maintain 1 of 1 resident's PRN pain medication on order which poses a potential health and safety risk to resident in care.Type B
To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by failure to notify the responsible party of 1 of 1 resident per facility Fall Response Procedure which poses a potential health and safety risk for resident in care.Type B
Report Facts
Capacity: 100 Census: 54 Deficiencies cited: 2 Plan of Correction Due Date: Aug 2, 2021
Employees Mentioned
NameTitleContext
Kristie LaineAdministratorMet with during complaint investigation
Pheej ChengLicensing Program AnalystConducted the complaint investigation
Maribeth SentyLicensing Program ManagerNamed in report as Licensing Program Manager
Inspection Report Complaint Investigation Census: 52 Capacity: 100 Deficiencies: 0 Jun 9, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility was not following care plans, not following doctor's orders for medications, and that staff were not being respectful to residents.
Findings
The investigation reviewed medication records, physician reports, nursing notes, service plans, and conducted interviews. The Department concluded that the allegations were unfounded.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis.
Report Facts
Capacity: 100 Census: 52
Employees Mentioned
NameTitleContext
Melissa LusbyEvaluator / Licensing Program AnalystConducted the complaint investigation
Marlene McCraryHealth Services DirectorMet with during the investigation
Faith BrownBusiness Office DirectorScreened the evaluator prior to entry
Kristie LaineAdministratorFacility administrator
Anthony PerezLicensing Program ManagerNamed in report as Licensing Program Manager
Inspection Report Annual Inspection Census: 54 Capacity: 100 Deficiencies: 0 May 26, 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. No deficiencies were cited as a result of the inspection.
Employees Mentioned
NameTitleContext
Kristie LaineAdministratorMet with Licensing Program Analysts during the inspection and involved in infection control domain completion.

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