Brookdale Auburn

Allegation investigated: Staff do not ensure the facility is properly maintained

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to open the investigation and deliver findings into allegation listed above. LPA met with Executive Director Malissa Acuna,during today’s visit. During today's inspection LPA conducted interviews, toured the facility and reviewed records pertinent to the investigation. ** Report continued on 9099-C page Unfounded Staff do not ensure the facility is properly maintained Records reviewed indicated that weekly and monthly checks on the fire system are conducted within the building. Interviews conducted indicated that monthly fire drills are conducted with staff to ensure staff know what to do in case of emergency. Staff radios are utilized for every staff with every shift and are checked monthly to ensure that all radios are working and connected to the system. Observations indicated that the fire panel is labeled and no hazards were seen around or on the panel. The overall building is within standards of operating per Department standards. Observations indicated resident rooms are properly furnished with appropriate bedding and lighting and bathrooms are operational. Common areas are clean and accessible to residents and kitchen meets Department standards. 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 Executive Director. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 59-AS-20260601121700

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Executive Director Malissa Acuna to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care facility to ensure compliance with Title 22 regulations. Facility has both assisted living (AL) and memory care (MC) wings. LPA observed resident rooms, common area bathrooms, kitchen, dining hall, common areas and perimeter of care facility. LPA observed resident rooms to be properly furnished, with appropriate bedding and lighting. The resident and common area bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care facility has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are hardwired and operational in the care home. Fire panel for the building is maintained and is operational. 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 six (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 4, 2026

Allegation investigated: Staff do not ensure that residents are provided adequately supervised, resulting in resident sustaining an injury Staff do not ensure that residents' incontinence needs are met Staff do not assist residents with showering

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director Malissa Acuna 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 do not ensure that residents are provided adequately supervised, resulting in resident sustaining an injury Interviews conducted indicated that resident R1 was supervised during shower and no injuries occurred. R1 sustained an skin abrasion after the shower where R1 slid down the wall to the floor to the seated position, no fall occurred. Records reviewed indicated R1 is not a fall risk and did not require hands on showering, only stand by assistance. Therefore, the allegation staff do not ensure that residents are provided adequately supervised, results in resident sustaining an injury unfounded. Staff do not ensure that residents' incontinence needs are met Interviews conducted indicated that staff are taking care of incontinence needs of all residents. Interviews with residents indicated that there is no concerns with incontinence care and staff are very helpful. Records reviewed indicated residents have incontinence needs indicated on their service plans which is followed by staff. Service plans are updated as needed or at least every six months. Interviews with residents R2, R3, and R4 indicated that there are no complaints with staff and the incontinence care that is received. Therefore, the allegation staff do not ensure that residents’ incontinence needs are met is unfounded. Staff do not assist residents with showering Interviews conducted indicated that staff are assisting with showering needs. Staff will assist a resident with a shower on their day and if a shower is refused, there are protocols in place to help attempt a shower again, like changing face of the staff member or changing the time of day. Sometimes, shower days are changed based on staff schedules which is communicated with residents. Interviews with residents R2, R3, and R4 indicated that there are no complaints with showering. Records reviewed indicated showers are provided and indicated on shower sheets. Showers are documented and skin checks are done to assess resident. Therefore, the allegation staff do not assist residents with showering 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, Nov 6, 2025 · control 59-AS-20250912093923

Type of visit: Required - 1 Year

On June 6, 2025 LPA Tryon visited the facility to conduct an annual inspection. LPA met with Executive Director Malissa Acuna. The facility currently has 97 residents. LPA toured the facility with ED including common areas, dining rooms, kitchen, hallways, resident rooms, bathrooms, medication room, recreation areas, offices. The facility is clean and in good condition. Rooms/apartments are nicely furnished and decorated. Maintenance appears to be ongoing as needed and facility is kept in good shape. LPA toured 6 resident apartments in Assisted Living, and 3 apartments in memory care. LPA was able to speak with 4 residents. LPA viewed fire extinguishers that were all charged and up to date. Fire system/alarms/carbon monoxide detector system installed, checked regularly. Last inspection was 5/15/2025. System is checked quarterly. Johnson Control is the company who checks the system. LPA toured kitchen and food storage. Kitchen appeared to be clean, well-furnished with pots and pans, utensils, necessary tools and appliances, and a good supply of dishes. Food supplies appear to be varied and of good quality. Supply appears to meet the requirement of 2 days perishable and 7 days non-perishable supplies. LPA reviewed 5 resident files and 3 staff files. Files appear to contain required documents and information. Staff records include training in required areas. Staff records include fingerprint clearance and/or exemptions. Medications are kept organized in locked med carts, inside a locked medication room. Most medications are in bubble packs. Centrally stored medication logs are maintained. Temperature in the building was comfortable. Residents appeared to be active and in good spirits overall. At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 6, 2025

Type of visit: Required - 1 Year

On June 18, 2024 LPA Tryon visited the facility to conduct an annual inspection. LPA met with Executive Director Malissa Acuna. The facility currently has 76 residents. LPA toured the facility with ED including common areas, dining rooms, kitchen, hallways, resident rooms, bathrooms, medication room, recreation areas, offices. The facility is clean and in good condition. Rooms/apartments are nicely furnished and decorated. Maintenance appears to be ongoing as needed and facility is kept in good shape. LPA toured 7 resident apartments in Assisted Living, and 6 apartments in memory care. LPA was able to speak with 3 residents. LPA viewed fire extinguishers that were all charged and up to date. Fire system/alarms/carbon monoxide detector system installed, checked regularly. Last inspection was 6/10/24 by the local Fire Marshall. System is checked quarterly. LPA toured kitchen and food storage. Kitchen appeared to be clean, well-furnished with pots and pans, utensils, necessary tools and appliances, and a good supply of dishes. Food supplies appear to be varied and of good quality. Supply appears to meet the requirement of 2 days perishable and 7 days non-perishable supplies. LPA reviewed 7 resident files and 7 staff files. Files appear to contain required documents and information. Staff records include training in required areas. Staff records include fingerprint clearance and/or exemptions. Medications were viewed. Medications are kept organized in locked med carts, inside a locked medication room. Most medications are in bubble packs. Centrally stored medication logs are maintained. Temperature in the building was comfortable. Residents appeared to be active and in good spirits overall. At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 18, 2024

Allegation investigated: Staff allow the residents to be soiled for an extended periods of time Insufficient staffing to provide adequate care and supervision Staff do not practice safe food handling techniques Staff do not properly maintain the facility grounds Staff do not provide hygiene products Staff are chemically restraining the residents while in care Staff are mishandling the residents medications Staff are yelling at the residents while in care

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Administrator Malissa Acuna during today’s inspection. LPA investigation allegation, “Insufficient staffing to provide adequate care and supervision”. LPA interviewed 5 residents that required care and supervision. 5 of 5 residents stated there are sufficient staff to meet their needs. 2 of 5 residents stated they have had to wait over 30 minutes for care at times. LPA interviewed 4 care staff at the facility, of which all stated there is sufficient staffing unless they have call offs. Care staff stated they are able to meet the residents’ care needs. Due to the information gathered LPA finds the allegation to be UNFOUNDED. Continuation on 9099-C. Unfounded LPA investigated allegation, “Staff allow the residents to be soiled for an extended periods of time”. LPA interviewed 5 residents in care in which they stated their care needs are being met. LPA interviewed 4 care staff in which they stated they have not observed residents soiled and left in an extended period of time. Care staff stated they have heard about times that has occurred, but they did not observe it. LPA interviewed administrator in which she stated she is not aware of residents being left soiled for an extended period of time. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated the allegation, “Staff do not practice safe food handling techniques”. LPA toured the facility kitchen, refrigerator, freezer, dry storage, and food preparation area. LPA observed 2-day perishable and 7-day nonperishable amount of food. LPA observed all food to be properly stored and all food appeared to be fresh and within the expiration date limits. Kitchen appeared to clean, sanitary, and free from smell. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated the allegation, “Staff do not properly maintain the facility grounds”. LPA interviewed 5 residents in which they stated the facility, and their room is kept clean at all times. 1 resident stated staff forget to empty their trash within their room on the weekends. LPA interviewed the administrator, in which she stated there is a housekeeper at the facility 7 days a week. Common spaces get cleaned daily, resident rooms get cleaned weekly, and sections of the facility get deep cleaned throughout the week. LPA interviewed 1 housekeeper in which she stated they clean the facility 7 days a week. LPA toured the facility and inspected common living spaces, resident rooms assisted living and memory care units, kitchen, and memory care unit. LPA observed the facility to be clean and sanitary with no smell present. Due to the information gathered, LPA finds the allegations to be UNFOUNDED. Continuation on 9099-C. LPA investigated allegation, “Staff do not provide hygiene products.” LPA interviewed 1 housekeeper in which they stated the facility provides the residents with basic hygiene items like toilet paper. LPA interviewed 5 resident in which they stated the facility provides them with basic hygiene products if needed. LPA interviewed administrator in which she stated there is a storage room full of basic hygiene items for residents if needed. LPA toured the storage room on the 2nd and 3rd floor which had toilet paper, soap, caregiver supplies, continence supplies, and other hygiene items. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, “Staff are chemically restraining the residents while in care.” LPA reviewed 4 resident medications, reviewing the present medications with resident MARS and physician orders. LPA interviewed 4 residents which required medication management from the facility staff. 4 of 4 residents stated they receive their medication daily and have had no problems with the medication management. LPA interviewed administrator in which she stated the medication technicians follow physician orders and give medications as prescribed. LPA interviewed 1 medication technician in which they stated if a hospice resident has a PRN medication order they call hospice before giving a PRN medication. Medication technician stated they follow medication orders which are on the resident MARS. Due to the information gathered LPA finds the allegation to be UNFOUNDED. LPA investigated, "Staff are mishandling the residents medications". LPA reviewed 4 resident medications, reviewing the present medications with resident MARS and physician orders. LPA interviewed 4 residents which required medication management from the facility staff. 4 of 4 residents stated they receive their medication daily and have had no problems with the medication management. LPA interviewed administrator in which she stated the medication technicians follow physician orders and give medications as prescribed. LPA interviewed 1 medication technician in which they stated they follow medication orders which are on the resident MARS. Due to the information gathered LPA finds the allegation to be UNFOUNDED. Continuation 9099-C. LPA investigated allegation, “Staff are yelling at the residents while in care.” LPA interviewed 5 residents in which they stated they have not been yelled at or observed any other resident being yelled at by facility staff. LPA interviewed 4 care staff in which they stated they have not observed any staff yelling at residents in care. LPA interviewed administrator in which she stated she has not observed any staff yelling at a resident in care. Due to the information gathered LPA finds allegation to be UNFOUNDED. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230821112726

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a case management visit. LPA met with Administrator Malissa Acuna during today’s inspection. During the complaint investigation, LPA discovered R1 was on hospice services. In September R1 went on a walk with activities with several other residents. During the walk R1 fell on the ground and was complaining of pain. Facility called hospice, and was told to wait for a hospice nurse to assess resident. R1 was helped up and moved back into the facility. Hospice arrived 2 to 3 hours later, and instructed staff to not send resident out for emergency services. The following day, resident was still in pain and facility sent resident out to the emergency department. R1 was diagnosed with a hip fracture and sent back to the facility on hospice services. Due to facility not calling emergency services upon R1’s injury which was not related to the expected course of the resident’s terminal illness, deficiencies are cited on 809-D. Exit interview conducted and copy of report provided. Appeal rights given.the state’s words, verbatim · CDSS document, Oct 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Oct 20, 2023

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: (3) Specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement is not met as evidenced by: Based on interviews the licensee did not call emergency services for R1 upon fall at the facility which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Administrator agrees to conduct a training with all care staff regarding hospice residents and emergency services. Copy of training materials and staff sign in sheet to be sent into CCL by 10/20/23.