Folsom Countryhouse

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Katherine Martinez, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed three (3) bedrooms on the first floor, two (2) bedrooms on the second floor, and two (2) 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 108 degrees F on the first floor and 107.5 degrees F on the second floor. 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, cleaning products and other toxins 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 checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) staff 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, Mar 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Katherine Martinez, to conduct a Required-1 Year Inspection. During today's visit, LPA reviewed six (6) resident 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, Mar 25, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on March 12, 2025 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed five resident (5) and five staff (5) files. All residents files contained the required paperwork. All staff files contained the required paperwork and training. LPA and ED Katherine Martinez toured the facility together to ensure the health and safety of residents in care. The areas toured included kitchen, hallways, memory care apartments, memory care dining room, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to ED.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Resident tested positive for a controlled substance which is not a prescribed medication.

On 3/6/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Resident tested positive for a controlled substance which is not a prescribed medication. On 12/7/2023, R1 was taken to the hospital with a chief complaint noted to be “confusion.” While R1 was at the hospital, a urine test was completed, and the results came back showing R1 tested positive for Fentanyl and amphetamine. R1’s prescribed medications list did not include Fentanyl or amphetamine. During the investigation, it was learned R1 is taking a medication called Wellbutrin. Per Hospital medical records, Wellbutrin can cause a false positive for amphetamines. The Director of Nursing and staff stated Folsom Countryhouse does not have any residents who have prescriptions for Fentanyl or amphetamines. Facility staff did not know how R1 tested positive for both Fentanyl and amphetamine. Medication Technicians reported that the medication room and medication cart are both locked, and they stated that the medication room or medication cart has never been left unlocked. Staff were asked if there were any concerns about staff using Fentanyl or amphetamines within Folsom Countryhouse and they said no. Residents were interviewed and had no complaints to report. Through interviews and record review, the Department could not find substantial evidence to support that the allegation occurred. 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. Exit interview conducted and copy of this report was left with Director of Nursing Brian Pawloski .the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 59-AS-20231214145225

Allegation investigated: Resident was raped in a facility

On 3/6/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski . During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Resident was raped in a facility During in investigation, it was reported that sometime in December 2022, R1 was inappropriately touched by staff at Folsom Countryhouse. During interviews, R1 was unable to provide details of the incident. It was noted that R1 has a diagnosis of Dementia and when interviewed, R1 was unable to recall residing at Folsom Countryhouse or any incidents that occurred at the facility. File review documents were obtained and reviewed. There were no notes or Incident Reports regarding the alleged incident. Through interviews and record review, the Department could not find substantial evidence to support that the allegation occurred. 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. Exit interview conducted and copy of this report was left with Director of Nursing Brian Pawloskithe state’s words, verbatim · CDSS document, Mar 6, 2024 · control 59-AS-20240214145950

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 3/6/24 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (10) and staff (9) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Director of Nursing Brian Pawloski toured the facility together to ensure the health and safety of residents in care. The areas toured included, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Food is within compliance. Water temperature is within the required range of temperature. Fire drills reviewed. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month. No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 6, 2024

Allegation investigated: Staff does not respond to residents call pendant in a timely manner. Staff mismanaged residents medication.

On 12/11/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with administrator, Danielle Peck. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Allegation- Staff does not respond to residents call pendant in a timely manner. The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During interviews, staff stated that staff respond to resident call buttons in a timely manner, however, sometimes there is a delay in response due to staff assisting other resident’s needs. During facility observation on 11/8/23 and 11/20/23 and call log review, the department did not observe any long/extended wait times from staff to respond to resident's call button, therefore this allegation is found to be 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. Allegation- Staff mismanaged residents medication. Based on documents obtained and statements received, the department determined that there was insufficient evidence that staff did not properly maintain medication for residents in care. Documents reviewed show that all current medications were administered and logged correctly and were given to residents per their doctor's orders from 11/1/23-11/17/23. Based upon the information obtained during investigation, the above allegation is 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 was conducted and a copy of this report was provided to the facility. Allegation- Staff forced resident to shower. Based on records reviewed and interviews conducted it was determined by the department that (per facility policy) if residents refuse to shower, staff will redirect, come back a few minutes later, or change face. If all those steps are taken, and residents still refuse to shower, staff then document refusal in the residents’ charts. From records reviewed, the department observed that staff were documenting all shower related documentation per facility policy and were not forcing any residents to take showers if they refused. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Facility does not have sufficient staff to provide care to residents. LPA has reviewed facility schedules which shows shifts are covered by multiple staff. There is no evidence to support the allegation that the facility does not have sufficient staff to provide care to residents. From records review, LPA learned that there are at least 2 direct care staff available on each floor during each shift for every day. Residents' interviews indicated that their needs are met, and the department finds no evidence that the current staff level is insufficient. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff did not properly supervise resident resulting in a fall. Based on records reviewed and interviews conducted, the department determined that R1 did not have any falls in the months of September, October, and November (2023). Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted and copy of this report has been provided.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 59-AS-20231103110803

Allegation investigated: Facility elevator is in disrepair.

On 12/11/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to do complaint investigation into the allegation listed above and met with administrator, Danielle Peck and explained the reason of today's visit. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.Based on interviews and records reviewed, the elevator broke on 12/05/23 and facility reached out same day to company who will repair it. Per facility records and interviews, elevator sensor was broken and new sensor will arrive around 12/12/23 and service company will complete all the repair work . Although the elevator was temporarily not in service, the plan to get residents downstairs was implemented and therefore the allegation is unsubstaniated, as there was no harm caused to residents in care. 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 was conducted with administrator and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 11, 2023 · control 59-AS-20231207150457

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff slapped resident Staff intimidated resident Staff did not report physical abuse of resident Staff do not treat clients with dignity and respect

On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff slapped resident Staff intimidated resident Staff did not report physical abuse of resident Staff do not treat clients with dignity and respect Based on records reviewed and interviews, it was determined that R1 was not slapped or abused by any staff at the facility. Based on interviews conducted, no marks were noticed on R1 after the incident was alleged. Records review indicated that R1 has a history of hallucinations and dementia and regularly says that someone is hitting someone. Law enforcement was involved, did their own investigation, and they did not substantiate the allegations above. Regarding staff not treating residents with dignity and respect, all residents interviewed stated that staff are very respectful to them and other residents, and no one had issues with staff. Staff and resident interviews did not indicate any physical abuse happening at the facility. Based on all this information, all above allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Director of Nursing and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 59-AS-20231012162435

Allegation investigated: Staff are not acknowledging resident's new POA documents.

On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: R1 was admitted to the facility on 7/27/23. Complaint allegations stated that R1 was placed in the facility against their will. Based on records reviewed and interviews, R1 has a family member as their POA. Based on R1’s medical diagnosis, R1 is not able to make decisions including the ability to change their POA. Staff are acknowledging that another family member wants to be POA, however, the facility cannot address that issue. LIC602 states that R1 is not medically competent to change the POA. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Director of Nursing and a copy of this report was provided to the facility. Unfoundedthe state’s words, verbatim · CDSS document, Nov 8, 2023 · control 59-AS-20231026084013

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Insufficient staffing to meet the residents needs while in care

On 10/11/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Executive Director Danielle Peck. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: ALLEGATION:Insufficient staffing to meet the residents needs while in care. LPA has reviewed facility schedules, and shifts are covered by multiple staff. There is no evidence to support the allegation that needs are not being met due to staffing. LPA learned that there are at least 2 direct care staff available on each floor during each shift. Residents indicated they feel that their needs are met, and LPA finds no evidence that the current staff level is insufficient. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left at facility. Unfoundedthe state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230817141449

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.