Brookdale Roseville

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to several incident reports (LIC624) recently submitted to the Department. LPA met with Anelise Fusneica, Assistant Administrator and stated the reason for the inspection. LPA later met with Monica Avalos, Health and Services (HSD) Director to discuss each incident report. The facility is a licensed for individuals who have a diagnosis of Dementia. LPA observed several residents, including (R1) ambulating with staff in the common areas. Resident (R1) exited through the front entrance on July 16, 2026 (2:26 pm) and staff immediately responded after hearing the door alarm. (R1) was located in the facility parking lot. On July 19, 2026 (1:30 pm) from the back door and located (5) minutes later in the parking lot. (R1) did not sustain any visible injuries after each incident. HSD stated that (R1's) medication, Valproic Acid/Depakote was decreased on June 28, 2026 and a week later, (R1) began showing increased aggression and exit seeking behaviors. On July 13, 2026, the HSD and family member discussed increasing the Depakota medication with the physician back to three times daily, and it was. (R1's) aggression has improved already but they are still showing some exit-seeking behaviors, until the new medication dosage takes full effect. LPA observed (R1) trying to exit, alongside a staff member, during today's inspection. The HSD expects the exit seeking behaviors to improve within the next week. (R1) understands how to open the doors but staff offices are near the front door, and the medication room is near the back door. Resident (R2) was sent to Emergency Room by home health medical staff on July 21, 2026 due to being confused, lethargic and showing a low heart rate. Lab work was done and (R2's) medications were evaluated with the Depakote dosage being decreased. (R2) returned to the community today, July 23, 2026. *cont on 809C-1.. 809C-1.. Resident (R3) was observed to have swelling on their left leg/foot on July 17, 2026 and was sent to the Emergency Room. The HSD stated the facility had been communicating with home health staff, but they were not coming out to assess (R3), due to apparently not receiving the orders from the doctor. (R3) was seen by their physician on July 10, 2026 and completed blood work on July 13, 2026. The HSD stated that (R3's) condition was gradually becoming worse and after (5) days was sent out after thing to contact home health. (R3) was treated for Cellulitis and Edema and was discharged with a (7)-day antibiotic and (3) days of Lasix. (R3) was approved to be admitted to Home Health on 7/22/26 and will receive nursing, physical therapy and occupational therapy. (R3) has been compliant with taking medications and staff will continue to monitor (R3) and encourage them to elevate their leg. The facility promptly sent residents (R2) and (R3) out for emergency medical care when observing a significant change in condition. LPA reviewed (R1's) Physician's Report that notes (R1) is not able to leave the facility unassisted due to their cognitive diagnosis and the associated wandering. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued due to (R1) being able to leave the facility and enter the parking lot, unassisted, on 7/16/2026 and on 7/19/2026. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(6) · Plan of correction due date: Jul 24, 2026

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement is not met as evidenced by: Based on documentation reviewed and an interview conducted, the Licensee did not ensure that resident (R1) was not able to exit the facility, unassisted, on July 16, 2026 (2:26 pm) and on July 19, 2026 (1:30 pm), which posed an immediate health and safety risk to residents in care. (R1) was located in the facility parking lot within 1-2 minutes and 5 minutes, respectively, following each incident, and with no visible injuries.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: The HSD recently conduct staff training on preventing resident elopements. Specifically, you trained staff to wait until the door alarm is bypassed and realarms, 30 seconds after the code is entered. Staff will ensure 30 seconds pass before walking away from the egress door. Additionally, staff has been providing 1:1 to (R1), when needed, during certain times of the day (1:00 pm- 8:00 pm) Documentation of training to be faxed to LPA by 7/27/2026.

Type of visit: Required - 1 Year

On 06/02/2026, Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director (ED), Abigail Vue, and explained the purpose of the visit. LPA and ED toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, and courtyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. Medications are locked and inaccessible to residents in care. First aid kit was complete. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguishers were last serviced on 05/12/2026. Fire drill was last conducted on May 30, 2026. LPA observed required Licensing posters posted in the facility. LPA reviewed a total of six (6) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of three (3) staff record. Staff training were completed and staffing files contained required first aid certificate. No deficiencies being cited during today's inspection. Exit interview conducted with Executive Director, Abigail Vue, and report provided.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Executive Director Abigail Vue to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care facility to ensure compliance with Title 22 regulations. LPA observed four (4) resident rooms, four (4) resident bathrooms, common areas, medication room, kitchen and dining room. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care facility has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Kitchen was in sanitary condition and organized to serve residents in care. Smoke detectors and carbon monoxide detectors are operational in the care facility. 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 five (5) resident files, four (4) 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 Executive Director.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Cassandra Mikkelson and Cheyenne Ratajczak met with Executive Director (ED) Abigail Vue to discuss two incident reports that had been sent to CCLD. LPAs conducted interviews, toured facility and collected pertinent documents related to each incident report for review. At this time, no deficiencies are being cited. LPAs will return if further follow up is needed. Exit interview conducted, copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Abigail Vue during today's inspection. LPA arrived to discuss recent COVID cases, incident report, and to clear out plan of correction from annual inspection. Administrator reported all COVID cases have been cleared and all residents are doing well. Incident report was discussed, and administrator reported R1 is receiving home health services for wound on feet. Administrator reports wound is not a pressure injury but home health is treating wound. LPA reviewed LIC602's for resident's concerning the plan of correction. LPA observed updated LIC602's for residents in care. POC cleared and letter of clearance provided. No deficiencies cited during today's inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with administrator Abigail Vue during today's inspection. Currently there are 12 residents residing at the facility of which 2 are receiving hospice care services. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, and outdoor spaces. In the areas toured no immediate health, safety, or personal rights violations were observed. This facility has an approved delayed egress system. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 5 resident files and 5 staff files. LPA reviewed 3 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. LPA observed not all care staff had updated CPR and first aid certificates, and health screenings. In addition resident records were found to be incomplete. Deficiencies are cited on 809-D. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit in regards to an incident report that was received. LPA met with Administrator, Janelle Douglas, during today's inspection. CCL received an incident report from the facility stating that during destruction of discontinued medications facility staff observed there was 2 packs of hydrocodone missing from the medication cart. Missing medications belonged to a past resident who no longer resides at the facility. LPA interviewed administrator in which the staff member responsible for medication destruction has been terminated. An internal investigation occurred and the investigation came back inconclusive. LPA reviewed medication policies, and medication destruction policies. Facility has reported missing medications to the local police department. Administrator stated they will be working on new procedures in regards to medication destruction. If changes occur to facility policy and procedures, Administrator agrees to send a copy into CCL for review. No deficiencies cited during today's inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 29, 2023

Allegation investigated: - Resident sustained an injury due to staff neglect. - Staff left hazardous item accessible to residents in care.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 10/03/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 02/16/2023. LPA met with Executive Director, Janelle Douglas, and explained the purpose of the visit. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, admission agreement, unusual incident/injury report, medical records, personal service plan, care profile, progress notes, temporary service plan wound, and transmission. Continued page LIC-9099C. Substantiated Allegation: Resident sustained an injury due to staff neglect. – Substantiated. According to interviews conducted, R1 sustained an injury while in the facility on 02/05/2023. R1 sustained a burn the size of a half dollar on R1’s left leg. The Department received an unusual incident/injury report on 2/12/2023 . Incident report indicated on 02/05/2023 staff were changing R1 prior to bedtime and observed blisters on R1’s left leg from the knee to mid-thigh. Staff provided first-aid and contacted EMT to request an urgent assessment and send out to the hospital. R1’s Power of Attorney (POA) and primary care physician were contacted as well as Executive Director. R1 refused to be transported to the hospital and POA agreed. Although R1’s burn was unwitnessed, interviews with staff and witnesses determined that R1 was burned from an electric fireplace that was located on the floor in the common area of the facility. On 02/07/2023, R1 was taken to the hospital due to high blood pressure and the burn wound appeared to be at risk for infection. R1 returned to the community the same day with wound care orders and supplies. The facility was to monitor R1 for pain or any signs or symptoms of infection. The facility nurse was to reassess the wound healing progress at 7 and 14 days to ensure proper treatment is being administered. Wound dressing changes were to be performed by Med Techs on shift, all of which had been properly trained on the wound cleanse and dress process. Medical records indicated that the R1’s burns were second and first degree burns to lateral left lower leg, knee, and thigh. At the time of R1’s hospital visit on 02/07/2023, burn did not show signs of infection and R1 is stable for discharge back to memory care facility. On 2/08/2023, R1 returned to the hospital concerning burn care. The hospital provided R1 with bacitracin, gauze, and nonadherent and tape and R1 returned to the community. On 2/13/2023, R1 returned to the hospital for re-evaluation of burn wounds. R1 diagnosed with third degree burn on left leg and will require daily wound care. R1 was discharged from the hospital and admitted to skilled nursing facility on 2/15/2023. R1 was admitted into the facility on 10/12/2021. The Department requested and reviewed R1’s physician’s report that was completed on 09/15/2021. According to R1’s physician’s report, R1’s primary diagnosis is progressive supranuclear palsy (PSP) and secondary diagnosis is dementia and Parkinson's. R1 cannot manage their own treatment, medication, and equipment. R1 has visual impairment, bowel impairment, bladder impairment, and motor impairment/paralysis. R1 uses an assistive device such as a walker and cannot walk unassisted. R1 is confused/disoriented and cannot locate self temporally or spatially. R1 has wandering behavior and is not able to leave the facility unassisted. R1 is non-ambulatory based upon both physical and mental condition. Facility completed R1’s personal service plan on 10/09/2021. According to R1’s service plan, R1’s PSP condition causes balance with balance, movement, coordination. R1 shuffles when R1 walks. Facility is to provide escort services and encourage and re-direct R1 to use walker. R1 requires physical assistance related to the inability to stand independently during dressing or grooming tasks, and bathroom tasks. R1 is independent going to and from the dining room or community activities. R1 can transfer self and needs standby assist occasionally. Care staff is to monitor R1’s gait and balance. The Department determined that although R1’s injuries were not a direct result of staff neglect, facility staff did however neglect to provide a safe environment and did not ensure that the electric fireplace was inaccessible to residents with a diagnosis of Dementia. Allegation: Staff left hazardous item accessible to residents in care. – Substantiated. According to interviews conducted, staff reported that that R1 was sitting too close to an electric fireplace which was located on the ground in the common area of the facility. This facility services residents with a diagnosis of Dementia and therefore must ensure that any items that could constitute danger to residents should be inaccessible. At the time of the incident, R1 was wearing shorts. On 2/5/2023, LPA Keosavang arrived at the facility unannounced to open complaint investigation. LPA met with Executive Director, Morgan Greenwood Whinery, and explained the purpose of the visit. LPA discussed allegations with ED and toured the facility with ED. ED indicated R1 was recently sent to the hospital due to an injury. ED indicated an unusual incident report was submitted to CCLD for review. A care staff had observed R1 with blisters on R1’s left leg during a change prior to bedtime. It was determined that R1 was injured due to a portable electric fireplace located in the common area. R1 was assessed by EMT and was recommended to be transferred to the hospital, however, R1 refused. Facility notified R1’s POA. LPA Keosavang observed the electric fireplace located in the common area of the facility. LPA observed the electric fireplace to be unplugged but still accessible to residents in care. ED pointed out that the facility had disconnected the wire on the electric fireplace so it cannot be connected to an outlet. ED stated electric fireplace will not be used moving forward. The Department interviewed a total of three (3) facility staff. Interview statements received from staff indicated that R1 had a habit of sitting close to the fireplace and moving around in their wheelchair. Based on interviews and observations, the facility did not ensure residents had a safe living environment by resident’s having access to an electric heater. The Department finds the above allegations 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. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. Failure to correct the deficiencies may also result in civil penalties. Appeal rights provided. Exit interview conducted and report provided. Allegation: Staff did not care for resident's wound in a sanitary manner. – Unsubstantiated. According to complainant, R1 had multiple burns. On 02/9/2023, complainant observed staff same in to R1’s room to treat the wound during the visit and laid the gauze and scissors on the dirty floor. Staff was wrapping R1’s injuries with dirty supplies. The Department interviewed a total of two (2) facility staff. S1 indicated the direction for the after care for R1’s burn is to keep the burn clean and dry. Staff is to dress R1 in shorts to ensure there was no irritation and it was easier to change the bandage for the burn. S1 indicated caregivers did not change R1’s wound and it was the responsibility of the nurse and Med Tech. On 8/10/2023, LPA Keosavang arrived at the facility to conduct complaint investigation. LPA requested to interview the nurse and Med Tech. According to Operational Specialist, Sharon Monck, nurse, and the Med Tech that provided wound after care is no longer working at the facility. The facility provided Med Tech’s contact information. On 8/25/2023, LPA called Med Tech and left a detailed message. LPA requested for Med Tech tor turn LPA’s call. LPA unable to receive interview statement from Med Tech. Allegation: Staff did not ensure resident had clean laundry. – Unsubstantiated. On 2/9/2023, complainant observed R1 not wearing shows. Socks that R1 was wearing were wet from something that R1 had been drinking spilling on R1’s feet. According to R1’s personal service plan, R1’s laundry days are Wednesday and Saturday. Staff is to assist R1 with the set-up, selection or laying out of clothes. R1 can perform the following tasks with physical assistance as needed, putting on/taking off clothing, socks, and shoes. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, caregivers in the morning shift are responsible for residents’ laundry. Caregivers are to check residents’ laundry basket every morning to see if they are full or not. Residents have their scheduled laundry days and if caregivers observed laundry baskets are full, they will make sure to do the residents laundry. S1 explained R1 did not have a lot of clothes so staff had to wash R1’s clothes more frequently compared to other residents in care. Housekeeper will also assist with laundry if needed. Interview statement received from S2 indicated, housekeeper assist with laundry, but it is the caregiver’s responsibility. S2 stated when caregivers see that residents’ laundry basket is full, they would do it right away or on their scheduled days. S2 stated if a resident in care had an incident caregiver would change out the sheets right away and throw it in the washer and dryer. Allegation: Staff did not ensure that resident was adequately fed. – Unsubstantiated. On 2/9/2023, complainant observed R1’s wheelchair was covered with food. Staff did not wipe R1’s hands after R1 ate a piece of chocolate cake with chocolate syrup. Staff don’t keep the facility clean, and the floors are covered with food. Complainant is concern with the amount of food R1’s eating in R1’s condition. R1 does not have use of both arms and struggling to eat due to Dementia. Complainant stated is concern that R1 was losing weight since R1 moved into the facility. According to R1’s personal service plan, R1 is on a regular diet. R1’s food is to be cut up in the kitchen. On 2/15/2023, LPA conducted a tour of the facility with Executive Director, Morgan Greenwood Whinery. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, R1 was on a regular diet. S2 stated there is plenty of food at the facility to feed all the residents in care. Allegation: Staff did not ensure resident's hygiene needs were met. – Unsubstantiated. On 2/9/2023, complainant observed R1’s wheelchair was covered with food. Staff did not wipe R1’s hands after R1 ate a piece of chocolate cake with chocolate syrup. Staff don’t keep the facility clean, and the floors are covered with food. According to R1’s personal service plan, R1 schedule showers days are Monday and Friday between 7am and 8am. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, R1 was able to feed self. S1 explained R1 would “make a big mess” when eating due to R1’s diagnosis. S1 stated when R1 would make a big mess when eating caregivers would take R1 back to R1’s room and wash/clean R1 and bring R1 back out to the common areas. Caregivers would assist R1 daily with brushing teeth, washing face, and showers on schedule days. Interview statement received from S2 indicated, R1 gets dirty when eating. S2 explained when R1 is finished eating caregiver would clean R1 right away. “They don’t leave him dirty.” S1 stated R1 is scheduled for showers two days a week and as needed if there are accidents. Allegation: Staff did not keep the facility clean and sanitary. – Unsubstantiated. On 2/15/2023, LPA Keosavang arrived at the facility unannounced and met with Executive Director, Morgan Greenwood Whinery. LPA toured the facility with ED. LPA observed common areas, courtyard, kitchen, medication room, and five (5) residents’ bedrooms and bathrooms. LPA observed the facility to be clean and sanitary. The Department has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report will be provided to the facility.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 25-AS-20230210141515

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Oct 4, 2023

87705(f)(1) Care of Personal with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on records review, observation, and interviews, electric fireplace located in common area was accessible to residents in care causing R1's injuries. This poses an immediate health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: The facility agrees to remove electric fireplace from the common area and submit a statement of understanding and compliance to CCL via email by POC due date, 10/04/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 4, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on records review, observation, and interviews, the facility did not ensure that electric fireplace was inaccessible to residents in care. This poses an immediate health, safety, and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: The facility agrees to review regulation section 87468.1 and submit a letter of understanding to CCL via email by POC due date, 10/04/2023.