Brookdale Folsom

Allegation investigated: -Facility failed to seek timely medical -Resident sustained unstageable wound while in care

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Shari Kranig, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, the department conducted interviews and obtained documentation pertinent to the investigation. Resident (R1’s) Personal Service Plan, dated September 9, 2025, indicated that the only activity of daily living (ADL) that R1 required assistance with was showering twice per week. R1 was independent going to the dining room or community activities, as well as self-managing their own medication, which included self-administering, ordering, coordinating, and safe storage. According to R1’s Progress Notes, on January 31, 2026, staff (S2) indicated that R1 was escorted back to their room due to weakness. R1 had indicated that their responsible party would deliver medication for their cold. Additional notes from January 31, 2026 **************************************************Continued on LIC9099-C************************************************ Unsubstantiated indicated that staff had checked up on R1 a few times throughout the evening and R1 stated that their responsible party had brought them medication. On February 1, 2026, staff checked on R1 and R1 stated that they were alright and taking their medication. Staff advised R1 to drink lots of fluids. On February 2, 2026, Progress Notes indicated that staff checked on R1 throughout their shift. R1 stated that they were feeling much better that day. On February 3, 2026, staff (S4) tested R1 for Influenza A and B and COVID. R1 tested positive for Influenza A. R1 was informed of masking and isolation requirements, as well as that meals would be delivered to them. Additional notes from February 3, 2026 indicated that R1 had been taking medication for their illness since January 31, 2026. R1’s symptoms were still present and R1 reported feeling lethargy and was coughing infrequently. On February 4, 2026, S2 indicated that R1 had been found that morning on the floor at around 8am and R1 was sent to the hospital. Emergency Medical Services (EMS) Records indicated that they were notified on February 4, 2026 at 7:58am regarding R1. EMS began their assessment of R1 at 8:03am. R1 did not experience any acute changes while in route to the hospital. Hospital records indicated that R1 was admitted to the hospital on February 4, 2026 due to being “found down”. Additionally, hospital records indicated that, on February 5, 2026, R1’s skin was assessed. R1 was observed to have a stage 1 pressure injury measuring 1.0x0.4cm as evidenced by non-blanchable redness, a deep tissue injury/unstageable pressure injury on buttocks measuring 10.0x9.0cm as evidenced by dark red/purple discoloration and slough noted, and a deep pressure injury on their right ischial lower buttock measuring 1.5x0.6cm as evidenced by dark red/purple discoloration. According to staff interviews and R1’s Personal Service Plan, R1 was independent with their ADLs and only required assistance with showering. R1’s shower logs indicated that they received a shower on January 29, 2026 and no skin issues were observed. R1’s shower logs indicated that they refused a shower on February 2, 2026. R1’s progress notes indicated that, on February 4, 2026, staff did not observe any skin injuries as a result of R1’s fall. Interviews with skilled professionals indicated that wounds such as R1’s could occur within hours. Based on interviews conducted and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 59-AS-20260629174042

Allegation investigated: -Due to lack of supervision, resident was on the floor for an extended period of time -Staff neglect resulted in resident being hospitalized -Staff did not notify authorized representative of change in condition

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Shari Kranig, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. According to resident (R1’s) Personal Service Plan, dated September 9, 2025, R1 self-managed their own medications, including self-administering, ordering, coordinating, and safe storage. R1 did not require assistance with dressing, grooming, toileting, and was independent going to dining room or community activities. R1 was able to shampoo their hair and wash their body with staff physical assistance as needed. R1 received showers twice per week. R1’s shower logs indicated that they received a shower on January 29, 2026 and no skin issues were observed. R1’s shower logs indicated that they refused a shower on February 2, 2026. Interviews with staff (S1, S2, S3, and S4) indicated that R1 was independent and was not considered a fall risk. **********************************************Continued on LIC9099-C*************************************************** Unsubstantiated R1’s Progress Notes and staff interviews indicated that, on January 31, 2026, R1 was escorted back to their room from the dining room due to weakness. Progress Notes indicated that R1 stated that their daughter will deliver some medication for their cold. Additional notes from January 31, 2026 indicated that staff had checked on R1 a few times throughout the evening and R1 stated that their family had brought them medication. Staff indicated that they advised R1 that, if they need anything, to let them know. Progress Notes from February 1, 2026 indicated that staff checked on R1 and that R1 indicated that they were alright and taking their medication. Staff advised R1 to drink lots of fluids. Progress Notes from February 2, 2026 indicated that staff checked on R1 throughout their shift. R1 had informed staff that they were feeling much better. R1 still had a cough and congestion, however, were feeling much better. Progress Notes from February 3, 2026 indicated that S4 tested R1 for Influenza A and B and COVID. R1 tested positive for Influenza A. The facility implemented their infection control plan. S4 indicated that R1’s responsible party was contacted and that both R1 and R1’s responsible party were thankful and appreciative of the help provided. Interviews with S1, S2, S3, and S4 indicated that, throughout the timeframe that R1 was ill, January 31, 2026-February 3, 2026, staff were checking on R1, food and drinks were being delivered to their room, R1’s garbage was being removed, and R1’s bed was being made. Staff interviews indicated that they did not observe R1 not eating or drinking. Progress Notes dated February 4, 2026 and interviews with S1, S2, and S3 indicated that, on February 4, 2026, R1 was found on the floor around 8:00am. S1, S2, and S3 indicated that the AM shift begins at 6am. Upon arrival, the AM staff meet with the NOC shift staff so night staff can report any observations made during their shift. S1 indicated that NOC shift makes their last rounds checking on residents around 5:30am. S3 indicated that, on February 4, 2026, the NOC shift did not report any changes to R1’s condition. S1 and S3 indicated that the AM shift begins their rounds checking on residents around 6:15am. S3 indicated that, when they checked on R1, they observed R1 in their recliner. S2 and S3 indicated that, around 8am, they were in the same hallway as R1’s room. S2 was providing medication to a resident near R1’s room and S3 opened R1’s door and observed R1 on the floor. S3 went to assess R1 and S2 joined them after they administered the other resident’s medication. S2 had made contact with S1 who was assisting a resident in the facility experiencing a medical emergency. S1, S2, and S3 indicated that emergency medical services (EMS) and the fire chief were already in the building when R1 was found. S1 and S2 spoke with EMS and the fire chief to also check R1. S2 indicated that they called R1’s responsible party via phone and were in communication with them throughout the incident. Staff indicated ************************************************Continued on LIC9099-C*************************************************** that R1’s responsible party also spoke with EMS. R1’s progress notes indicated that there were no physical signs of head injury and there were no signs of skin injury as a result of the fall. Notes also indicated that R1’s responsible party and health care provider were contacted. EMS records indicated that they were notified on February 4, 2026 at 7:58am regarding R1. EMS began their assessment of R1 at 8:03am. Records indicated that R1 was sitting on their walker. R1 were fully awake, fully oriented, and neurologically intact at the time of assessment, however, seemed lethargic at times. R1 had been found on the floor of their room by staff in the morning and it is unclear how long they had been on the ground. R1 did not recollect falling or how they got on the ground. R1 had no outward signs of trauma and no complaints regarding their head, neck, or back. R1 denied any dizziness, weakness, chest pain, shortness of breath, nausea, vomiting, cough, fever, or any other flu-like symptoms. R1 was negative on the stroke scale and blood sugar was normal. All other vitals were normal. R1 was able to stand and pivot to the gurney with assistance. Lastly, R1 experienced no acute changes in route to the hospital. Hospital records indicated that R1 was admitted on February 4, 2026 due to being “found down”. The hospital course indicated that R1 had a history of hypothyroid, prior CVA, seizure disorder, cognitive impairment, and history of breast cancer presenting after they were found down. R1 was treated for community-acquired pneumonia and mild dehydration. R1 was quickly weaned off oxygen and improved with antibiotics. Throughout their admission they frequently voiced passive thoughts of death although they denied any depressions and any active suicidal ideations. They were very clear in their DNR/DNI code status but at this time did not appear to have any criteria for hospice. They were sent to skilled nursing facility in stable condition. Their family was involved and frequently updated. Additional notations from hospital records indicated that, on February 5, 2026, R1’s skin was assessed. R1 was observed to have a stage 1 pressure injury measuring 1.0x0.4cm as evidenced by non-blanchable redness, a deep tissue injury/unstageable pressure injury on buttocks measuring 10.0x9.0cm as evidenced by dark red/purple discoloration and slough noted, and a deep pressure injury on their right ischial lower buttock measuring 1.5x0.6cm as evidenced by dark red/purple discoloration. R1 was discharged from the hospital on February 7, 2026 to the skilled nursing facility. Interviews with skilled professionals indicated that wounds such as R1’s could occur within hours. **********************************************Continued on LIC9099-C**************************************************** According to R1’s progress notes and interviews with S1, S2, S3, and S4, the facility was in communication with R1’s responsible party throughout their change in condition beginning January 31, 2026-February 4, 2026, when they were sent to the hospital. On February 5, 2026, CCLD received an Unusual Incident/Injury Report LIC624 indicating that, on February 4, 2026, R1 was found on the floor in their apartment at around 8am and was transported to the hospital. The LIC624 also indicated that the facility notified R1’s responsible party. Based on interviews conducted and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 59-AS-20260526143632

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Shari Kranig, to conduct a case management visit in relation to a separate inspection conducted on today’s date, August 27, 2026. LPA reviewed resident (R1's) documentation. R1 resided at the care home from September 2018-March 2026. The facility did not have documentation of R1's annual routine visit with a licensed medical professional. The facility had a physician's report LIC602A with an exam date of October 15, 2024, as well as three (3) fax confirmations indicating that they faxed R1's primary care physician attempting to obtain an updated LIC602A. However, the facility did not obtain an updated LIC602A or an after visit summary indicating that R1 was seen for their annual routine visit. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1) · Plan of correction due date: Sep 10, 2026

87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure resident (R1) had documentation on file indicating they had their annual routine visit with a licensed medical professional, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: Facility agrees to submit a plan regarding how they will ensure all residents have documentation indicating they received an annual visit with a licensed medical professional. Facility shall submit the plan to LPA by the POC due date of 9/10/26.

Allegation investigated: -Facility staff falsified resident's medical condition

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Health and Wellness Director (HWD), Dianne Palmer, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Resident (R1’s) Personal Service Plan, dated January 7, 2026 and signed by R1’s responsible party on January 8, 2026, indicated that care staff would be providing Chronic Condition Management. The chronic health condition selected on R1’s Personal Service Plan was Heart Failure, indicating that staff should be alert of swelling of the hands and feet, shortness of breath and activity intolerance, and sudden weight gain. ***********************************************Continued on LIC9099-C*************************************************** Substantiated Comments were added to the chronic health condition indicating hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysarthria, and gastrointestinal hemorrhage. According to R1’s Medical Assessment LIC602A, dated January 7, 2026, R1 had the diagnoses of vascular dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysarthria, gastrointestinal hemorrhage, gait abnormalities, heart murmur, edema, hx of stroke, hx of ischemic transient ischemic attacks, atherosclerosis of aorta, osteoporosis, atherosclerosis of aorta, along with multiple other health conditions. The facility’s Chronic Condition Management Infographic form indicated that dementia and stroke management are considered chronic health conditions. Although R1 required care staff management with their chronic health conditions, and they have diagnoses that may lead to heart failure, R1’s physician did not specify R1 had a diagnosis of heart failure. The facility did not correctly identify R1’s medical diagnosis as part of their personal services, which would affect the information provided to care staff on what symptoms they should be monitoring. Based records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. On May 15, 2026, resident (R1’s) progress notes time stamped 10:24am indicated that the HWD was notified by care staff and med tech that R1 was “in a deep sleep not able to wake up not easily aroused”. The progress notes also indicated that R1 was not able to take their medications due to not being easily aroused, in a deep sleep, and not responding to call or touch. R1 was still asleep and breathing. Fax correspondence dated May 14, 2026 to R1’s physician indicated that R1 was experiencing a significant change in their condition even after starting Keppra medication. R1 was not tolerating a mechanical soft diet with regular liquids well and continued to aspirate during meals. R1 was sleeping most of the day and frequently spitting out their medications. R1 was also no longer participating in any ADLs independently. The facility indicated that they were requesting advice regarding further recommendations for R1’s plan of care. Fax correspondence dated May 15, 2026 to R1’s physician indicated that staff notified the HWD that R1 did not take their morning medication as they were not easily aroused and in a deep sleep. R1 fully woke at around 10:30am and vitals were taken. The facility requested that the physician reassess R1 and change R1’s diet order as R1 was having difficulty swallowing with a mechanical soft diet and was aspirating. On May 15, 2026, R1’s physician responded to the facility indicating that, if R1 was having difficulties/worsening of swallowing, then they could place a referral to a speech therapist for a more formal swallow study; however, R1 either needed to be able to get to the appointment or needed to be seen by them in person so they could place a home health order. On May 18, 2026, a fax was sent to R1’s physician to send an order for supplemental shakes and to complete a physician diet order form as R1’s responsible party had been bringing R1 boost plus shakes. The facility did not have a physician’s order for the shakes. On August 18, 2026, LPA conducted a tour of the kitchen area and observed the facility has the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. In the kitchen, there was a modified diet board on the wall indicating all residents who require a modified diet along with their names, photos, and room numbers. The board is also organized by type of modified diet. Interviews with staff (S1) indicated that the cooks ensure that the modified diets are followed. S1 indicated that the residents’ plate lids are labeled with the type of modified diet and color coded. LPA observed the labels being used. S1 indicated that food and snacks are all sent to memory care. LPA observed that, in memory care, there are snacks and drinks available such as apple sauce, Jello, yogurt, fruits, sugar free ice cream, soda, water dispenser, coffee, and juice. Interviews with R2, R3, R4, R5 and residents (R6 and R7) indicated that the food is good and they are getting plenty to eat. Interview with R2 indicated that they believe their modified diet is being followed by the care home. S2, S3, S4, and S5 indicated that R1’s diet was followed based on **********************************************Continued on LIC9099-C*************************************************** physician’s orders. LPA also received a copy of the facility’s weekly menu, the alternative menu for assisted living, and the August snack menu for memory care. Each menu provides a variety of food options for residents in care. Interviews with S2, S3, S4, and S5 indicated that care staff always ensured R1 was receiving assistance with their activities of daily living (ADLs). S2, S3, S4, and S5 indicated that R1 was never left soiled or wet. Interviews indicated that R1 was never left in bed or their wheelchair for an extended period of time. Interviews with staff also indicated that they do not keep a log of when they provide assistance with ADLs. Interviews with R2, R3, R4, R5, R6, and R7 indicated that all of their care needs are being met. R3, R6, and R7 indicated that they are never left wet or soiled. R4 and R6 indicated that they are being checked on by care staff frequently throughout the day. R2, R3, R4, R5, R6, and R7 indicated that they have no concerns regarding the care being provided at the facility. Based on interviews conducted, observations made, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. According to the facility’s Price Schedule, the facility charges $175 for specific care and/or monitoring due to chronic conditions with some examples listed as edema and activity intolerance. The facility’s Chronic Condition Management Infographic form indicated that dementia and stroke management are considered chronic health conditions. R1’s Medical Assessment LIC602A, dated January 7, 2026, indicated that R1 had the diagnoses of vascular dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysarthria, gastrointestinal hemorrhage, gait abnormalities, heart murmur, edema, hx of stroke, hx of ischemic transient ischemic attacks, atherosclerosis of aorta, osteoporosis, atherosclerosis of aorta, along with multiple other health conditions. R1’s Assessment Summary indicated that they were being charged for medication management, chronic condition management, nutrition, dressing and grooming, showering and bathing, bathroom assistance, and two person transfer or mechanical lift. According to R1’s Account History Report, they were charged the correct dollar amount for all personal services each month. According to R1’s Admission Record, their admission date was January 8, 2026. Email correspondence dated May 27, 2026 from R1’s responsible party to the ED and Health and Wellness Director (HWD) indicated that R1’s responsible party was emailing as a formal 30-day notice that R1 would be transferring from the facility on June 4, 2026. R1’s Progress Notes indicated that R1 moved out of the care home on June 4, 2026. R1’s Account History Report indicated that they were charged a prorated amount for care and rent the month of June as they moved out of the care home on June 4, 2026. Based on documentation obtained, the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or are without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 59-AS-20260519152705

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Sep 3, 2026

87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any…misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on records reviewed, the facility selected the incorrect medical diagnosis for (R1’s) personal services, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: Facility agrees to create a plan to ensure that they are correctly identifying residents’ medical diagnoses in their personal services and submit to LPA by the POC due date of 9/3/26.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Shari Kranig, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed five (5) bedrooms in assisted living, two (2) bedrooms in memory care, and six (6) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 107.3 degrees F on the first floor in assisted living, 107.7 degrees F on the second floor in assisted living, and 109.7 degrees F in memory care. 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. LPA observed knives and cleaning products to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Shari Kranig, to conduct a Required-1 Year Inspection. During today's visit, LPA reviewed five (5) resident files and five (5) staff files. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to conclude annual inspection. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Jun 30, 2026

Allegation investigated: -Staff are mismanaging residents' medications -Staff were not checking resident's blood pressure resulting in hospitalization -Staff did no ensure resident had water resulting in dehydration

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Sheri Kranig, to deliver complaint investigation findings into the above stated allegations. During the course of the investigation, LPA conducted a medication count, conducted interviews, and obtained documentation pertinent to the investigation. Allegation: Staff are mismanaging residents' medications On October 24, 2025, LPA conducted a medication count for residents (R2 and R3), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed two (2) medications for R2 that were over the amount documented. LPA observed one (1) medication for R3 that was over the amount documented. *******************************************Continued on LIC9099-C************************************************** Substantiated Allegation: Staff were not checking resident’s blood pressure resulting in hospitalization According to resident (R1’s) personal service plan, facility staff are to “consider possibility of orthostatic hypotension and respond as needed”. R1’s progress notes indicated that, on October 5, 2025 at 12:19pm, R1 was not feeling well, had no fever, but said that their stomach aches. R1’s progress notes indicated that, on October 6, 2025 at 9:44am, R1 indicated that their stomach was cramping. Progress notes indicated that facility staff would contact R1’s responsible party to have them take R1 to the doctor. The facility does not have any progress notes between September 18, 2025 and October 5, 2025 indicating any observations of R1. R1’s responsible party indicated that when they arrived at the care home R1 did not look well and they were told by staff that R1 had not been eating and had been staying in bed for the past 3 days. R1’s responsible party indicated that, on October 6, 2025, they took R1 to a routine doctor’s visit where they were informed that R1 had low blood pressure and needed an EKG. According to hospital records dated October 6, 2025-October 7, 2025, the chief complaint was R1 “not feeling well, GWK, sleeping more than normal, dizziness x a few days. Patient from Brookdale. Patient saw cardiologist this AM, BP was low at the clinic”. Hospital records indicated that R1 was diagnosed with hypotension likely secondary to component of dehydration and antihypertensive medications. Hospital records indicated that they made adjustments to R1’s antihypertensive medication regimen. R1 was released from the hospital on October 7, 2025, however, R1’s responsible party did not return R1 to the facility. Allegation: Staff did not ensure resident had water resulting in dehydration According to hospital records dated October 6, 2025-October 7, 2025, R1 was diagnosed with hypotension likely secondary to component of dehydration and antihypertensive medications. Hospital records indicated that R1 was provided with IV fluids, due to diagnosis. Based on medication count, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Allegation: Staff are not meeting resident’s dietary needs According to ED and staff (S1, S2, S3, and S4), the facility followed R1’s special diet plan as directed by their physician. R1’s physician’s orders indicated that they are on a low-carb diet and avoid sugary snacks and juices. LPA observed that the kitchen has a board that they utilize to inform all kitchen staff of what residents are on a special diet and the type of diet. Interviews with residents (R4 and R5) indicated that the facility is following their special diets and they don’t have any concerns. Allegation: Staff did not ensure privacy during visits Interview with ED indicated that there are several areas in the memory section as well as assisted living that residents can have private visits with their visitors. LPA toured facility and observed all areas available for private visits in memory care and assisted living. Interviews with R4 and R5 indicated that there are no issues with having private visits at the facility. Allegation: Staff did not ensure dishes were cleaned and sanitized Interviews with ED indicated that a cart goes to the kitchen from memory care to ensure dishes are sanitized. S1 indicated that clear clean cups are provided to residents for drinking. R4 and R5 indicated that all dishes provided to residents are clean. LPA toured the kitchen area and observed staff washing/sanitizing dishes. ED and S2 indicated that R1 had a personal water bottle provided by their responsible party, however, they typically don’t utilize personal water bottles in memory care. ED and S2 indicated that R1’s personal water bottle was not dirty and was not being used. ED, S1, and S2 indicated that they have self-serve water stations in both memory care and assisted living. They also indicated that residents are offered water from the stations or in disposable water bottles. ************************************************Continued on LIC9099-C********************************************* Allegation: Staff did not ensure resident had access to a telephone Interviews with R4 and R5 indicated that they have not needed to use the facility phone, but it is available, if needed. ED and S2 indicated that there were times when R1’s responsible party would call to speak to R1, however, R1 would be dining, napping, or may not want to talk. ED and S2 indicated that they would inform R1’s responsible party to call back. S2 indicated that majority of the time R1’s responsible party would call R1 would speak to them. S2 indicated that they would always inform R1’s responsible party if R1 was busy or didn’t want to speak on the phone. ED and S2 indicated that they always have a phone available for residents. Based on interviews conducted, documentation obtained, and observations made, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 59-AS-20251023095816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 14, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication counts and records reviewed, the facility did not ensure that residents (R2 and R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Facility agrees to conduct an in-service training with Med-Techs on medication administration and the importance of accurate documentation. Facility will also begin conducting medication audits to ensure there are no errors. Facility will submit information regarding in-service training and medication audit, including time and date of in-service and training material, to LPA by POC due date of 1/14/26. Facility requested an extension for 1/23/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 14, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on documentation reviewed, the facility did not ensure R1 was observed for symptoms of possible changes in blood pressure, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Facility agrees to conduct an in-service training with staff regarding observation of residents. Facility will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 1/14/26. Facility requested an extension for 1/23/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 14, 2026

87464 Basic Services (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on documentation reviewed, the facility did not ensure resident (R1) was maintaining proper hydration, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Facility agrees to submit a statement of understanding as well as conduct a staff training to ensure staff understand the caregiver expectations. Facility will also submit a list of all staff who attended the training by the POC due date of 1/14/26. Facility requested an extension for 1/23/26.

Allegation investigated: -Illegal eviction.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Shari Kranig, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. According to interviews, the facility did not evict resident (R1) from the facility. Additional information obtained in relation to R1 is under review and LPA may return on a later date for follow-up. Based on interviews conducted, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Dec 18, 2025 · control 59-AS-20250925150720

Type of visit: Required - 1 Year

Licensed Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and initially met with Cody Schweitzberger, Maintenance Director, and then Shari Kranig, Administrator and Dianne Palmer, Health and Wellness Director. The community is licensed for (130) residents, all of whom may be non-ambulatory, and (15) of whom may be bedridden. There is an approved hospice waiver for (15). Currently, there are (12) residents under hospice care. LPA and Administrator toured the interior of the Assisted Living Unit and the Memory Care Unit, including the common areas, main kitchen, dining rooms, salon, theater/library, Med-Tech areas, activity room and stairwell. There are exterior courtyard/patios in each unit with a walking path in the Memory Care Unit. LPA observed the facility to be clean, in good repair and odor free. Hot water was tested in (2) Assisted Living resident rooms and in (2) Memory Care resident rooms- all temperatures measured at 109-110*F. The main kitchen was toured and observed to have 2+ days of perishable food, including fresh produce, and 7+ days of non-perishable food. The fire extinguishers were last serviced 1/14/2025 and local fire recently inspected. Each stairwell has an evacuation chair and staff have completed recent training. There was live-music today in the afternoon, and the facility also offers outings to residents. Inside temperature measured 70-74*F. LPA reviewed vehicle records, Emergency Evacuation plan, and other documentation, including recent Shut Off Valve training. (5) resident files and (2) medications were checked- paper/electronic documentation is current and care plans are personalized. (5) staff files were reviewed- all staff is cleared/associated and regularly completes required training. Administrator's RCFE Certificate is valid thru 1/15/27. Multiple posters are visible in the common area. Facility to update CCLD and LTCO's contact information in the Admission Agreement.There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Shari Kranig, and the Health and Wellness Director (HWD), Dianne Palmer, to conduct a case management visit regarding an Unusual Incident/Injury Report received by the Department on 3/12/2025. On 3/11/2025, staff (S1) alerted the HWD that, at approximately 11:40 AM, resident (R1) was observed in the care home parking lot by staff (S2). S2 had redirected and escorted R1 back into the care home. The HWD assessed R1 and there were no injuries observed or noted. The facility notified R1's physician and responsible party of incident. Interview with HWD and ED indicated the R1 had exited memory care through the main door by following staff (S3). The alarm door to memory care did not close completely after S3 exited, which allowed R1 to follow. S2 was on their break in the parking lot and immediately observed R1 in the parking lot. S2 then redirected R1 back into the care home. HWD reviewed the elopement policy with staff and tested the alarm doors to ensure they were in working order. On 3/26/2025, the facility conducted an in-service training, which covered elopement and missing residents' resources, reducing the risk of elopement, early signs of exit seeking, missing resident policy, missing resident response worksheet, and Dementia care. There was an additional training conducted on 3/26/2025 that covered the facility's fire and elopement drill. During today's visit, no deficiencies were cited. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/18/24, and met with the Executive Director (ED), Sharyl Kranig, to conduct a case management visit regarding an Unusual Incident/Injury Report and SOC341 received by the Department on 9/16/24 and 9/17/24. On Sunday, 9/15/24 at approximately 12:15pm, resident (R1) reported to facility staff that sometime during Saturday night they had been physically abused and sexually assaulted by staff (S1). The facility contacted R1's responsible party and the local police department. The police department generated a report, and R1 and responsible party refused further medical exam or treatment. R1 was examined after the incident by facility staff and there were no physical injuries observed. The facility suspended S1 until their internal investigation was completed. The facility found the allegations to be unsubstantiated. S1 is not scheduled to work at the care home on Saturday and was not present in the care home the night that the alleged incident occurred. It was discovered that R1 was watching crime related television shows, which R1's responsible party removed from their television. On 9/17/24, R1 was taken to the hospital to be treated for potential UTI. R1 returned to the facility on 9/17/24 and was diagnosed with a UTI. R1 is scheduled to begin antibiotic medication. The facility has a meeting scheduled with R1's responsible party today, 9/18/24, and they are in the process of reassessing the resident for change in condition. Upon R1's return to the care home, the Health and Wellness Director conducted a brief interview for mental status of R1, which indicated a change in R1's cognition. The facility provided LPA with R1's hospital discharge documents, medication list, and progress notes. LPA reviewed the facility's internal investigation with ED. Staff schedule was provided to LPA as well. During today's visit, no deficiencies were cited. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Sep 18, 2024

Allegation investigated: Staff member provides care under the influence of drugs and alcohol

On 8/7/24, Licensing Program Analyst s (LPAs) Kevin Mknelly and Graham Gunby conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Dianne Palmer, Health and Wellness Director. The department conducted records review and extensive interviews. The department is unable to find and or meet the preponderance, per policy. An anonymous report was received by the department on 5/6/24, with limited details alleging S1 has been under the influence of illegal drugs and alcohol while working at Brookdale – Folsom RCFE. Multiple attempts to identify and contact the reporting party were unsuccessful. Current and former staff, as well as residents were interviewed and reported that S1 is a very good employee Unsubstantiated and caregiver. There were no reports of any concern or suspicion that S1 had ever been under the influence of drugs or alcohol while working at the facility. There was no documented relevant disciplinary action or concerns in S1’s employee file. S1 was interviewed and denied ever being under the influence of drugs or alcohol while working at the facility. Based on information obtained, there is not a preponderance of evidence to substantiate the allegation. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with Dianne Palmer and report copy provided.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 59-AS-20240506111114

Allegation investigated: Staff left resident in soiled briefs for extended period of time. Staff did not meet resident’s care needs. Staff are not sufficiently trained.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on 4/8/24. LPA met with receptionist who stated the Administrator was temporarily unavailable and allowed LPA to complete today's report in the private dining room. LPA met with the Administrator, Shari Kranig, later during today's inspection. In April and May 2024, the Department interviewed the Administrator, the Resident Care Coordinator, multiple facility staff ("am" and "pm" shifts), hospice personnel (2) and resident’s family member. The Department reviewed documentation pertaining to resident (R1), including hospice care notes, physician's report, care plan, and staff training records. The results of the investigation are as follows: cont on 9099C-1... Substantiated 9099C-1.. Allegation: Staff left resident in soiled briefs for extended period of time. The allegation states resident (R1) has been found in heavily urine soaked briefs, on several occasions, and (R1) had to have been left in soiled briefs for at least four hours. The allegation states caregiver states that R1 wouldn’t let them change (R1). Resident's (R1) physician reports (9/14/22) states resident has a diagnosis of Dementia. (R1's) care plan, dated 3/22/24, notes that (R1) demonstrates anxious, disruptive or obsessive behaviors, and hospice notes indicate (R1) began receiving hospice care in December 2023. All facility staff interviews revealed resident (R1) can be resistant to care. The Administrator, at the time, stated multiple approaches have been tried to get (R1) to do care with staff. The Resident Care Coordinator (RCC) stated (R1) is "checked every 2 hours but there are times when she is physically aggressive with staff and staff has to leave the resident alone", explaining (R1) will "push and scream", mostly when she is being changed, so staff will return in 10 minutes and try to provide the care again. The RCC commented that after 2-3 attempts, staff can try PRN Lorazepam- sometimes (R1) will take it and it works, but if she doesn't take it, it takes 2-3 caregivers to change her. One lead staff stated (R1) is very particular with receiving assistance with Activities of Daily Living (ADL's) and about not being touched, adding (R1) has "soaked through her Depends" as she "will refuse toileting at least once a week". Two additional staff stated it takes two staff to change (R1's) diaper or clothes, or get her in the shower, as (R1) is "combative and will try to hold (keep) her pants on". One of the staff stated they will notify the Med-Tech if a resident won't let staff change them, and staff will try again in 10 minutes, stating "putting things on is not the problem- it's taking them off". One staff stated she has had to remind care staff to change (R1) before and when hospice visits (R1), stating she feels it is a combination of staff not attending to residents and being tired as some staff are working "double shifts and 6 days/week", adding "things get busy but we try to change residents every 1-2 hours". Interviews revealed (R1) is "totally incontinent now" since December 2023 and "won't even go in the bathroom now without screaming". *cont on 9099C-2... 9099C-2...An outside care provider stated "it's hard to tell if it's neglect or if the resident is refusing care, explaining "(R1) can get combative and needs two staff to change her". This staff indicated that sometimes (R1) is "Very wet or soiled" but it's difficult to know if staff may be "trying to avoid confrontation" since (R1)has behaviors. Resident's family member stated in May 2024 that hospice staff has "been frustrated with the care", explaining, (R1's) rash started around Mar/April 2024 and hospice staff told facility staff to check (R1) "more often". Hospice records show that on 2/2/24 (5:45 pm), when (R1) was seen for wound care, resident was found in urine “soaked diaper” and was changed by the hospice nurse since there was not an available caregiver. Hospice notes indicate (R1) was somewhat resistant to the care provided. Additional hospice notes indicate that on 3/19/24- (9:00 am), the hospice nurse arrived and found resident with a saturated diaper, and on 4/5/24 (3:00 pm), the nurse arrived and found resident with both a saturated diaper and wet pants. Staff was instructed verbally to change resident's diaper frequently to prevent skin breakdown and a Urinary Tract Infection (UTI) and verbalized their understanding. In May 2024, a hospice nurse stated staff has been doing a better job than in previous months, and (R1), is "not laying 6 hours in a diaper", stating she has visited at different times and on different days (i.e. 7:30 am and 6:00 pm on weekends and week days) and they know what day she's coming back for the next visit. A second hospice staff stated she sometimes finds (R1) where she hasn't been changed timely, stating she is also concerned that (R'1s) clothing, or at least her top, is "not being changed daily", adding it's important since the elderly can "shred dry skin". Based on information obtained, LPA 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. *cont on 9099C-3.. 9099C-3.. Allegation: Staff did not meet resident’s care needs. Complaint alleges on 4/5/24, R1 was observed to not be wearing compression stockings, and when (R1's) slip-on-shoes were removed, it was observed that (R1’s) left foot was covered in dry feces. On 4/6/24, Home Health/Hospice Aide. found dried feces in R1’s shoes again. 1- Hospice notes document that (R1) was not found wearing compression socks on the following days: 2/21/24, 2/25/24, 3/3/24, 3/19/24,4/15/24, and on 4/26/24 when the hospice nurse visited. Hospice records show (R1) was wearing the compression socks on 4/9/24. On 4/10/24, LPA Angela Hood observed (R1) to appear to be clean and to be wearing compression socks. LPA confirmed (R1) received a bath earlier that day, in the morning. LPA toured (R1's) room and observed a sign posted, dated 11/22/23, reminding staff to not forget to put R1's socks on in the morning and take them off in the evening. On 5/23/24, LPA Calzada observed (R1) to be wearing a pair of compression socks (black), along with clean, dry clothes, and her hair to appear clean and styled. When touring resident's room, LPA asked to see extra pairs of compression socks but staff was not able to locate a pair. LPA observed a sign posted above (R1's)dresser instructing staff to "put compression stockings on every morning and remove every night". LPA was not able to observe if (R1) was wearing compression socks on 7/22/24 as LPA was informed that (R1) had passed on 6/20/24. Staff interviews revealed that (R1) had multiple pairs of compression socks, but staff lost one pair, and the socks possibly disappeared in the laundry. A Med-Tech stated how staff is supposed to put the socks on every day, but there are still times when (R1) is not wearing them at the right times, due to her refusing to let staff take them off, and she will sometimes kick and scream when being changed, indicating medication changes have been made a few times to assist with behaviors. A caregiver stated staff will take the socks off after the shower, during the "pm" shift and it's possible they were left off after the shower and one pair was missing and (R1) "also hides stuff, and would hoard napkins and spoons". Staff stated, in May 2024, compression socks are part of (R1's) care plan and the Memory Care Director printed out (R1's) care plan and told staff a month ago they need to follow the care plan of putting the socks on in the morning and taking them off at bedtime. A hospice staff stated, in May 2024, that staff have been better about putting the compression socks on regularly, and she is not concerned with any other residents, stating (R1's) "behaviors are why she is difficult". *cont on 9099C-4.. 9099C-4...2- Hospice records document that on 4/5/24 (3:00 pm), when the nurwse removed R1’s slip on shoes, she found the bottom of (R1’s) left foot covered in dry feces. A second hospice staff confirmed that on 4/6/24, she found dried feces on one of the insoles of a pair of (R1's) shoes and that she observed this during the "pm" shift, and staff tried to blame it on other shift person. This staff confirmed resident's shoes were washed right after feces was noticed on 4/6/24. One caregiver staff stated that she was not aware of dried feces being found in (R1's) shoes, but that it's possible this may have happened as (R1) sometimes has "standing accidents" and has a "lose bottom" (or diarrhea) and or urine leak. This staff stated (R1's) shoes are washed "often", but that it's possible an accident occurred one time, and it was not caught by staff. 3-On 3/21/24, hospice records note that resident (R1) had missed several “pm” doses of Seroquel on: 3/12, 3/15 and 3/20, and several “am” doses of Seroquel on 3/12, 3/15, 3/18 and 3/20. Hospice notes indicate that a Med-Tech stated the medications were missed due to (R1) falling asleep. Notes document that the Hospice nurse left instructions that the "pm" dosage of Seroquel needs to be given before bed, as prescribed and the “am” dose needs to be at or after breakfast. Based on information obtained, LPA 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. *cont on 90099C-5... 9099C-5... Allegation: Staff are not sufficiently trained. The complaint alleges that staff are not trained to work with clients with Dementia and resident (R1) needs to wear compression socks but staff do not place them on R1. In March 2024, when the compression stockings were not on R1, caregiver (S1) initially stated she didn’t know where they were, but after the socks were found, stated they were too hard to place on (R1). Staff were interviewed about training received. One Med-Tech stated that when staff are first hired, they spend the first 3 shifts (8 hrs/each or 24 hrs) completing approved on-line training before working on the floor with residents. This staff stated the Business Office Director manages staff training. One caregiver stated she completed on-line training and 2 weeks of shadowing, including "reverse shadowing" which is a "good process". This staff stated all caregivers are now trained this way and it's "helpful", and she feels all staff is "pretty well trained" and also receives monthly in-service training. Another caregiver stated that after she was hired, she shadowed staff and then "they shadowed me”, and she does not believe staff need additional training, asserting, "No, everyone has the same amount of training- it's who puts in the effort". The Resident Care Coordinator was asked if staff is trained to handle behaviors related to Dementia and stated "absolutely- some newer staff can call management or the Med-Tech if they have a difficult person". RCC confirmed new staff complete on-line training and then complete 3-4 days of shadowing, and the Business Office Director monitors the on-line training completed by staff. Staff training records for (14) staff were provided in April 2024. Review of the records showed that staff (S1) and multiple other staff had completed the required initial training hours but had not always completed the required training for each year thereafter. Based on records reviewed, LPA 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. There are (3) deficiencies issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 22, 2024 · control 59-AS-20240408112425

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Aug 24, 2024

87625 Managed Incontinence- (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on hospice records reviewed, the Licensee did not ensure that resident (R1) was kept clean and dry, on 2/2/24, 3/19/24, 4/5/24, and on 4/26/24, when hospice was at the facility to see (R1), which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Licensee/Administrator agree to .... conduct training with all staff on 7/24/24 (Wed) regarding incontinent care. A separate all staff training will be scheduled with Memory Care staff on 7/31/24. Documentation to be submitted by 8/12/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 24, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was provided with the personal assistance and care in ensuring her compression socks were worn as ordered, shoes and feet were kept clean on 4/5/24 and 4/6/24, and Seroquel medication was given as ordered, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Licensee/Administrator agree to .... conduct training with all staff on 7/24/24 and a separate training with all Memory Care Staff on 7/31/24. Documentation to be submitted by 8/12/24

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625 · Plan of correction due date: Aug 12, 2024

§1569.625 Staff training; legislative findings; contents (b)(2) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on review of (14) staff training records, provided in April 2024, many of the staff, including (S1), did not complete the required annual training, specifically to Dementia care, following the initial year of employment, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Licensee/Administrator agree to review all staff training records to ensure that all staff have completed both initial and continuing yearly training, as required per the HSC 1569.625. Documentation is due to the Department by 8/12/24.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 18, 2024 to follow up on an incident that was received by the Department on 7/14/2024. LPA learned that R1 has a routine of wandering throughout memory care and the memory care courtyard. LPA obtained R1's physicians report, current care plan, and hospital discharge paperwork. They are diagnosed with Dementia. On July 4, 2024, R1 was found in the courtyard, sweating and having labored breathing. LPA interviewed caregivers and med tech who were on duty on the date of the incident. Per staff, R1 is checked on hourly. Staff could not remember the specific time that they last saw R1 however, R1 was observed walking in the courtyard prior to lunch, which is a part of their daily routine. As the food was being served, staff were notified that R1 was in distress. Staff then followed protocol for a medical emergency. Since the incident, the facility has since began to utilize the alarms on the interior courtyard doors to alert staff when a resident goes out to the courtyard. These alarms are to be on when there is excessive heat. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 6/20/24 and met with the Resident Care Coordinator, Carla Marks, and Health and Wellness Director, Sharisse Toves, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in Assisted Living, two (2) bedrooms in Memory Care, and seven (7) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 105.4 degrees F. 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. LPA observed knives to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA continued reviewing resident and staff documents from previous visit. LPA reviewed six (6) staff files and five (5) resident files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 6/13/24 and met with Maurissa Eidenshink, Business Office Manager, to conduct a Required-1 Year Inspection. During today's visit, LPA reviewed three (3) assisted living resident files and two (2) memory care resident files. LPA also reviewed two (2) staff files. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to complete annual inspection. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/25/24, and met with the Health and Wellness Director, Sharisse Toves, to conduct a case management visit regarding an incident report received by the Department on 4/15/24. On 4/11/24, resident (R1) was found at a coffee shop down the street from the facility. The coffee shop employee called the police. The police arrived at the coffee shop and used R1's phone to call their responsible party. The police returned R1 back to the facility. No injuries were reported. R1 resides in the assisted living section of the facility and is currently receiving hospice care. On 4/15/24, the Department received R1's Physician's Report LIC602A, dated 7/5/22, which indicated that R1 is unable to leave the facility unassisted. On 4/24/24, the facility conducted an in-service training with all staff regarding missing residents/elopement. As a result of today's visit, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87464(f)(1) regarding care and supervision of residents. The deficiency is listed on the LIC809-D. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 26, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure that residents R1 was properly supervised, resulting in AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Facility conducted an in-service training following the AWOL with all staff regarding missing residents/elopement. Facility provided a copy of the in-service training to LPA by the POC due date of 4/26/24.

Allegation investigated: -Facility mismanaged resident's medications

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 3/6/24, and met with the Executive Director, Kristine Clawson, to open a complaint investigation and deliver findings into the above stated allegation. During today's visit, LPA obtained documentation pertinent to the investigation and conducted a medication count for 3 residents. ************************************************Continued on LIC9099-C************************************************* Substantiated LPA conducted a medication count for residents (R1, R2 & R3), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed one (1) medication for R1 that was over the amount documented and there were four (4) medications for R1 that were under the amount documented. LPA observed five (5) medications for R2 that were over the amount documented. LPA observed that two (2) medications for R3 were over the amount documented. LPA also observed during the medication count that there were several other residents that didn't have start dates for their medications. According to the facility's Order Summary Report and interviews conducted with the Executive Director and Health and Wellness Director, R1 had a new prescription for Losartan Potassium 25mg tablets that was ordered by the prescribing physician on 2/27/24. Facility Progress Notes for R1 dated 2/29/24 indicated that staff (S1) contacted R1's physician's office requesting that the medication order be faxed to the pharmacy. Progress Notes dated 3/3/24 indicated that S1 contacted R1's responsible party informing them that the facility was having issues getting the new prescription filled. Progress Notes also indicated that R1's responsible party would provide R1 with the their discontinued medication until the facility was able to get the new prescription filled. R1 did not begin receiving their new prescription until 3/5/24, which was 7 days after the original physician's order date of 2/27/24. Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 59-AS-20240304081051

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 7, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Facility agrees to have all med-techs sign a statement of understanding of job duties to address medication management to submit to LPA by the POC due date of 3/7/24. Faciliy will also complete bi-weekly audits of all medications for the next month and submit to LPA.

Allegation investigated: Staff did not issue resident a refund.

On 2/21/24, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Executive Director to deliver investigation findings. LPA reviewed staff records, facility records, and conducted interviews. LPA finds that facility met Tittle 22 requirements. LPA interviewed the Director and reviewed R1's admission agreement. R1 resided at the facility for 1 day and decided to move out. Resident moved out but continues to have until March 4 under their 30 day notice. The licensee has committed to reimburse more than is required. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report provided. Unfoundedthe state’s words, verbatim · CDSS document, Feb 21, 2024 · control 59-AS-20240214150905

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 1/29/24, and met with the Health and Wellness Director, Sharisse Toves, to follow-up on a case management visit regarding an SOC341 that was received by the Department on 1/9/24. On 12/13/23, resident (R1) reported to facility staff (S1) that staff (S2) was rough with them. S1 immediately informed the Executive Director, Kristine Clawson. On 12/13/23, The facility placed S2 on suspension pending internal investigation. S2 did not have further access to R1. Folsom Police Department (PD) was notified of the incident and created an incident report #2312140053. No formal case was opened with Folsom PD as they did not suspect abuse. At the conclusion of the facility's internal investigation, they did not find S2 abused R1. On 12/14/23, the facility terminated S2, due to other ongoing performance issues. The Health and Wellness Director indicated that the facility has been having issues with their fax machine and had to resend the SOC341 on 1/9/24. The original sent date was 12/14/23. No deficiencies were cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Hood arrived at the care home unannounced on 1/12/24 at met with Executive Director, Kristine Clawson, to conduct a case management visit regarding an SOC341 received by the Department on 1/9/24. During today's visit, LPA conducted an interview and requested pertinent documentation. No deficiencies were cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 12, 2024

Allegation investigated: Staff did not adequately supervise residents resulting in a resident hitting another resident.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/04/2023 to deliver complaint finding Community Care Licensing received on 07/18/2023. LPA met with Health and Wellness Director, Sharisse Toves, and explained the purpose of the visit. Throughout the course of the investigation, the Department conducted interviews with facility staff and reviewed pertinent documentation such as, residents’ (R1 and R2) physician’s report, service plan, SOC 341, staff schedule, and police report. Continue on LIC9099-C. Unsubstantiated According to police report, police officer responded to a call for possible domestic violence on 7/18/2023. R1 and R2 are diagnosed with Dementia. An incident occurred on 7/16/2023 around 6 PM, a staff was assisting R1 and R2 into bed. R2 was being uncooperative with staff and R1 got frustrated and slapped R2 across the face. R2 grabbed onto R1’s arm. There were no injuries and family were called. There are some minor incidents where R1 may be frustrated during mealtime and kick R2’s foot under the table. Interview with staff indicated facility’s management has a plan in place to redirect R1 during a behavioral outburst. According to R1’s service plan, R1 displays aggressive and obsessive behavior with R2 at times requiring staff attention and intervention. Interviews conducted with staff indicated, staff would conduct rounds to check on R1 and R2 every hour. The Department conducted a thorough investigation, there was no evidence to suggest that the facility was negligent in their care and did not adequately supervise residents resulting in R1 hitting R2. Staff was present during the time of the incident and redirected residents right away. The Department could not find enough evidence to confirm nor deny this allegation happened. The Department finds this allegation to be UNSUBSTANTIATED - meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies being cited for today’s visit. Exit interview conducted and report left at the facility.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 59-AS-20230718132033