Brunswick Village

Allegation investigated: Staff left resident in soiled diaper for an extended amount of time. Due to lack of staffing residents’ needs are not being met. Facility is malodorous. Staff do not follow proper food practices/preparations. Staff do not follow proper sanitation practices.

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Kristie Laine to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded Staff left resident in soiled diaper for an extended amount of time. Interviews conducted indicated that staff are checking on residents for incontinence support. Staff will take residents to the restroom before or after meals, before and after activities and whenever requested by the resident. Interviews with residents indicated that they feel their toileting needs are being met. Residents stated that they do not have to wait long for assistance and are checked on frequently to see if care assistance is needed. Residents interviewed did not have any complaints regarding toileting needs. Therefore, the allegation staff left resident in soiled diaper for an extended amount of time is unfounded. Due to lack of staffing residents’ needs are not being met. Interviews conducted with residents indicated that their needs are being met and there are no complaints regarding staff care. Staff are attentive and polite without issues. Interviews indicated that there are plenty of staff to assist with toileting, bathing and activities. Observations indicated that staff are assisting with residents care, cleaning rooms and checking on residents who are in their rooms. Therefore, the allegation due to lack of staffing, residents’ needs are not being met is unfounded. Facility is malodorous. Observations made during walk through on 07/21/2026 and 08/04/2026 of the building and grounds indicated that no odors are present in common areas or resident rooms. Interviews conducted indicated that there a occasional smells noted but it is only after changing a resident or if a resident has an incontinence accident. Staff are constantly aware of any smells or odors that may arise and are quick to clean up. Therefore, the allegation facility is malodorous is unfounded. Staff do not follow proper food practices/preparations. Records reviewed indicated that all kitchen staff are properly trained on food practices and preparations. All food preparation staff have current certificates for food preparation and sanitation practices. Observations indicated that staff in the kitchen were following food preparation practices and using gloves when preparing food. Staff were seen passing out foods to residents seated at the dining tables in both Assisted Living and Memory Care units. Food came straight from the kitchen on covered carts and given straight to the residents at tables. Therefore, the allegation staff do not follow proper food practices/preparations is unfounded. **Continued on 9099-C2 page Staff do not follow proper sanitation practices. Observations indicated that staff were actively cleaning resident rooms, common areas and bathrooms used for resident or guest use. Housekeeping was seen cleaning resident rooms and ensuring no cross contamination was occurring between rooms. Staff seen using gloves while assisting residents in care and changing gloves for new use. Chairs and tables were clean and sanitary. Interviews conducted indicated staff are trained in proper cleaning protocols and they feel that the facility is clean and sanitary. Residents interviewed have no complaints regarding the cleanliness of the facility. Therefore, the allegation staff do not follow proper sanitary practices is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 59-AS-20260713152312

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Executive Director Kristie Laine to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care facility to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas and outside sitting areas. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed eight (8) resident files, five (5) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2026

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA started toured with Clayton Fowler, Maintenance Director and Executive Director Kristie Laine finished the tour with LPA. This facility has 56 bedrooms. There is one one-bedroom apartment with a full bathroom and the rest are studio apartments with full bathrooms; some shared and some private. There is a memory care unit that has 12 rooms; some shared and some private. The memory care unit has a sitting area and dining area and a locked medication cart. The memory care unit is also secured with a delayed egress system. There is a courtyard in the middle of the facility building. The first floor has the kitchen and dining area, offices for administration, and a couple of common areas. The second floor has a common area, beauty shop, and the medication room. There is also a courtyard to the left of the main entrance side of the building. Several rooms were toured. Several resident records and staff training records were reviewed. A few topics were discussed. No deficiencies cited during this visit.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Staff does not prevent outbreak of scabies.

LPA Hiratsuka, conducted the investigation into the allegation above. LPA reviewed one resident's record and interviewed staff. There is one resident who is being treated for a skin issue for the past several months. The skin issue is not contagious per the doctor who is treating the resident. The resident in question is not required to be quarantined. No residents or staff have come down with any rashes or contagious diseases. Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. nothe state’s words, verbatim · CDSS document, May 6, 2025 · control 59-AS-20250505093340

Allegation investigated: Staff are not adequately trained to meet residents needs

Licensing Program Analyst Kerry Hiratsuka conducted this unannounced complaint visit to deliver the results of the allegation above. LPA interviewed Administrator and staff. LPA reviewed training documents. The training topics are colostomy care and catheter care. Some staff had training in December 2024 for catheter care, but not all. There was no training on colostomy care. There are currently a couple of residents who use these devices and the staff are required to have training on the types of devices that are used to take care of residents. The residents are being monitored by hospice agencies and did not suffer any ill effects. The staff training for colostomy care and catheter care started in April 2025 and is still in process. Substantiated Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Please see 9099-D for the deficiency sitedthe state’s words, verbatim · CDSS document, May 1, 2025 · control 59-AS-20250408092005

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d) · Plan of correction due date: May 30, 2025

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.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: By 05/30/2025, all the licensee shall submit in writing a plan to ensure staff get training on any adaptive devices that residents require.

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Clayton Fowler, Maintenance Director. This facility has 56 bedrooms. There is one one-bedroom apartment with a full bathroom and the rest are studio apartments with full bathrooms; some shared and some private. There is a memory care unit that has 12 rooms; some shared and some private. The memory care unit has a sitting area and dining area and a locked medication cart. The memory care unit is also secured with a delayed egress system. There is a courtyard in the middle of the facility building. The first floor has the kitchen and dining area, offices for administration, and a couple of common areas. The second floor has a common area, beauty shop, and the medication room. There is also a courtyard to the left of the main entrance side of the building. Several rooms were toured. Several resident records and staff training records were reviewed. A few topics were discussed. The following shall be updated and submitted to Licensing by June 1 2024: -LIC 500- facility personnel or staff schedule -LIC 308- designation of administrative responsibility. (who is in charge when administrator is not present.) - copy of liability insurance No deficiencies cited during this visit.the state’s words, verbatim · CDSS document, May 15, 2024

Allegation investigated: . Staff do not provide adequate food service to resident. 2. Staff do not treat resident with dignity. 3. Staff do not ensure a comfortable living environment for resident.

LPA Hiratsuka conducted the investigation into the allegations above. LPA Hiratsuka conducted interviews, reviewed files, and walked around. 1. One resident stated the food served is spoiled and not cooked and served properly. The one resident showed LPA pictures of grapes and to LPA the grapes appeared to have a blemish, not spoiled. LPA could not determine the condition of the fruit because it was a picture. Nine other residents interviewed have no issues with the food and stated the food is really good and no issues with the way it is served. The cooks have all the required qualifications per Title 22 regulations. LPA observed the food supply and did not observe any spoiled food. LPA is unable to prove or disprove the allegation. Unsubstantiated 2. One resident stated the staff are very rude to them. Staff interviewed stated there is one resident who cannot be pleased no matter what they do. Nine residents interviewed stated the staff are very good to them. LPA observed interactions between residents and staff during visits dated 04/10/2024, and today and did not observe any negative interactions. LPA cannot prove or disprove the allegation. 3. One resident stated there is an issue with the kitchen and it causes the apartment to vibrate and have loud noises. The one resident was offered to move to another apartment and the one resident refused. Executive Director Kristie Laine had the walk-in refrigerator and walk-in freezer inspected and the company that did the inspection did not find anything wrong with the units. LPA interviewed the residents in the apartments on both sides of the one resident with the issues and those residents do not have any issues. LPA interviewed seven other residents and they also stated there were no issues. LPA cannot prove or disprove the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 59-AS-20240205165106

Type of visit: Case Management - Deficiencies

LPA Hiratsuka observed during an investigation the licensee changed the dates of the annual rate increase from the anniversary date to the beginning of the year and did not have signed agreements from the residents stating that everyone is in agreement with the change of date for the annual fee. Title 22 Regulation Admission Agreements 87057(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. The admission agreement for one of the residents that was signed in 2017 states "to cover annual operating, maintenance, insurance, and other cost increases, you can expect an annual increase in Basic Rent and the Services Rate on the 12 month anniversary date of this agreement." The licensee did do the proper increase in annual fees by giving a 60 day notice as required, but did not get the signed modification date change for the increase itself. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87057(d) · Plan of correction due date: May 25, 2024

Admission Agreement. The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This requirement was not met as evidenced by: Based on resident file records review, Licensee did modified the date of raising the annual fee without having a written agreement to it which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: By 05/25/2024, the licensee shall come up with a written agreement stating how they shall ensure the regulation and submit it to Community Care Licensing Division.

Type of visit: Case Management - Other

LPA Hiratsuka conducted this visit to deliver an amended report for complaint #59-AS-20231109113548, that was delivered on 11/30/2023. The findings of unfounded has not changed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jan 11, 2024

Allegation investigated: . Staff do not provide residents with activities while in care 2. Staff do not provide residents with clean linen 3. Staff do not ensure resident rooms are kept clean

LPA Hiratsuka, conducted this unannounced complaint visit to deliver the results into the allegations above. LPA reviewed resident files and conducted interviews with residents and staff. LPA also obtained cleaning schedules and other documentation. 1. LPA observed residents participating in activities during today's visit and on 11/16/2023. LPA also interviewed residents and all but one stated there were are activities. LPA learned the one resident that stated there are none does not chose to participate in activities. LPA observed two separate activity calendars. Allegation unfounded. 2. LPA observed laundry being done during today's visit and on 11/16/2023. LPA interviewed residents and all but one stated their linens get cleaned. Facility has documentation about the one resident refusing service. Allegation unfounded. Unfounded 3. LPA obtained the housekeeping schedule and all rooms are cleaned by housekeeping once a week or as needed. Interviews stated all but one resident has their room cleaned. The facility has documentation stating when the one resident allowed staff to clean and not clean their room. LPA inspected twelve rooms and all were clean. Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. no deficiencies citedthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 59-AS-20231109113548