Brookfield Home Care

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday May 5, 2026 to conduct an unannounced case management visit. This visit is a health and safety check in response to R1 who was relocated to this facility on Saturday May 2, 2026 from another facility. LPA spoke with R1 today. LPA toured R1's room. LPA did not observe any deficiencies. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 5, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday April 16, 2026, to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (4) and staff (2) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Administrator Ramona toured the facility together to ensure the health and safety of residents in care. The following areas were inspected: resident bedrooms, bathrooms, kitchen, laundry room, garage and backyard. Facility was current on fire drills. Facility had a fully stocked first aid kit. All required postings were observed. All chemicals and knives were kept locked and inaccessible to residents. Fire extinguisher had a current inspection tag. LPA obtained a copy of current liability insurance. Exit interview conducted. No deficiencies cited. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Administrator Ramona McGill to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed five (5) resident rooms, two (2) common area bathrooms, kitchen, common areas and perimeter of care home. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files, one (1) staff files and two (2) resident medications. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 1, 2024 to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (4) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA Parks and Administrator Ramona toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed. All required posting were observed. Facility has a fully stocked first aid kit. Facility is current on fire drills. All chemicals and sharp objects were kept locked and inaccessible to residents. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.the state’s words, verbatim · CDSS document, May 1, 2024

Type of visit: Office

An Informal Conference was conducted on Wednesday March 13, 2024, in the Sacramento North Regional Office. The purpose of this informal conference meeting is to discuss repeated citations regarding staff fingerprint clearance requirements within the last 12 months. Present in the meeting is Licensing Program Manager, (LPM) Maribeth Senty, Licensing Program Analyst, (LPA) Melissa Parks, and Licensee Ramona McGill. The facility has been issued five (5) Type A citations in the past two years. The facility was cited under the following regulations: 1) Criminal record clearance, 2) Basic services requirement, and 3) Fire clearance. The licensee was informed that this Informal Conference is a part of the Administrative Action process, and that further citations may result in an elevation to a formal Non-Compliance Conference, which could lead to a referral to the Department's legal division for possible revocation of license. Issues discussed during the meeting were: · Non-eligible employee · Staff clearance requirements prior to working. · Staff Training requirements. The facility stated they will do the following to achieve continued and substantial compliance: · Administrator to contact Guardian and utilize for future staff hires. Secondary, contact regional office for staffing rosters if necessary. · Utilize Technical Support Program No deficiencies were cited during today’s meeting. An exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 13, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Melissa Parks and Kevin MKnelly arrived on Tuesday February 6, 2024, to conduct a case management visit and met with staff. LPAs spoke with the Administrator on the phone and explained the purpose of the visit. On January 2, 2024, LPA Parks arrived at the facility to begin a complaint investigation. At the time of the visit, S1 was at the facility with another staff member. Following the visit, LPA checked for S1’s criminal background clearance and association to the facility and found that S1 was not eligible to work in a licensed facility. As a result of this incident, the following deficiency was cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Civil penalties were issued. Exit interview conducted. A copy of this report and appeal rights were emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 7, 2024

Criminal Record Clearance. (e ) All individuals subject to a criminal record review …shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ...This requirement was not met based records and observation. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2024

Plan of correction: Administrator agrees to submit a statement of understanding regarding fingerprint clearance needed before staff are able to begin working at the facility.

Allegation investigated: Staff allow children to hit residents in care Staff allow children to harass residents in care

LPA Parks arrived on Thursday January 25, 2024, to conclude a complaint investigation regarding the above allegations. LPA met with staff Vivien Jighere and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, staff, residents, and family members. The result of the investigation is as follows: Interviews revealed that while the Licensee’s children visit at times, they have never been observed to interfere with resident care. Additionally, interviews acknowledged that no one has witnessed these children hitting or harassing residents in care. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was emailed to the Administrator Unfoundedthe state’s words, verbatim · CDSS document, Jan 25, 2024 · control 59-AS-20231229085437

Type of visit: Case Management - Deficiencies

On 10/19/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator. On 10/10/23, LPA Mknelly delivered complaint findings to the facility. At the time of the visit, caregiver S1 was at the home and providing resident care and supervision. The Administrator was away from the facility at the time, leaving S1 as the sole caregiver. Following the visit, LPA checked for S1’s criminal background clearance and association to the facility and found that S1 had not been cleared. Communication with the administrator also found that S1 did not have required health screening nor training. As a result of this incident, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Civil penalties are also issued. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 26, 2023

Criminal Record Clearance. (e )All individuals subject to a criminal record review …shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ...This requirement was not met based records and statements. This posed a risk to residents.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Staff are not working until clearance is approved. Licensee will submit a backup staffing plan and new LIC 500 by the POC date of 10/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Nov 2, 2023

Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met based on statements and records. This posed a potential riskthe state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee will submit a statement of understanding and intent to follow this requirement by the POC date of 11/2/23.

Allegation investigated: Staff slapped resident Staff neglecting resident

On 10/10/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with caregiver. Administrator spoke by phone and is unavailable to attend. LPA conducted records review and interviews. LPA is unable to find and or meet the preponderance, per policy. On 9/3/23 R1 was reported, by the licensee, to have had an aggressive episode toward a caregiver (S1) at approximately 10 AM due to R1 not wanting to take medications. The facility staff called hospice. Hospice nurse responded at approximately 2:30 PM and Hospice records reported that R1 was no longer agitated. On 9/4/23, some time after midnight, R1 left the facility unassisted and walked to a neighbor’s yard. R1 reported that a caregiver had hit R1 when R1 refused to take medications. Facility staff (S2) was working on the overnight of 9/4/23. S2 had reportedly used the restroom and when they returned to the common area, S2 saw the front door open and that R1 had gone outside. Unsubstantiated A police report concluded that based on the totality of statements provided the officer did not have probable cause to believe R1 was physically abused by caregivers at the home. In the allegation, it was also alleged that R1 had sustained a back injury. Interviews with family of R1 confirmed that R1 had had x-rays that found a spinal fracture but that it was of unknown origin or when it may have occurred. Before admission to this facility, R1 had had a fall at skilled nursing that resulted in injury. However, no x-ray was done at that time. R1 also had a fall on 8/24/23, at this facility, at which time he said that he thinks his back was broken. On 8/25/23 was when the back fracture was diagnosed. R1's responsible party stated that the fracture could have occurred prior to admission. Family stated that following R1's fall in Skilled Nursing, R1 has undergone rapid recline. With conflicting accounts of the 9/3/23 event by caregivers and R1 and that R1 did not continue to state that staff hit R1 in R1’s account to hospice, the department is unable to find a preponderance of evidence whether staff hit R1 or of R1 hit staff. Additionally, staff interviews, hospice records nor family statements found neglect of R1’s care needs. The issue of R1’s leave from the facility unassisted on 9/4/23, is addressed in a separate facility report. 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 administrator and report provided to designee Sandra Janette Garcia.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 59-AS-20230905104828

Type of visit: Case Management - Deficiencies

On 10/10/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver . Administrator spoke by phone and is unavailable to attend. On 9/27/23, licensee provided a statement that on 9/4/23, some time after midnight, R1 left the facility unassisted and walked to a neighbor’s yard. Facility staff (S2) was working on the overnight of 9/4/23. S2 had reportedly used the restroom and when they returned to the common area, S2 saw the front door open and that R1 had gone outside. Licensee also reported that the alarm to the front door was inoperable. Also on 9/27/23, LPA observed that the door alarm had not yet been repaired. At the time of the 9/4/23 incident R1 had a prescription for medication as needed for sleep. 8/28/23- 9/2/23, facility records show that R1 was given the medication daily for sleep. However, records did not show R1 having received the medication. The facility’s plan of operations states that all exterior doors have an operational bell/buzzer or other auditory device to alert staff when the door is opened. LPA and licensee reviewed reporting requirements related to other incidents in which R1 was involved. As a result of the investigation, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided to designee.the state’s words, verbatim · CDSS document, Oct 10, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Oct 24, 2023

Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, ... This requirement was not met based on statements and observation that R1 had known overnight sleeplessness and that R1 was able to leave unobserved. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee has repaired the existing door alarms. Licensee will submit the plan to upgrade their door alarms and additional measures for overnight supervision to ccl by the POC date of 10/24/23.