Brookdale Folsom.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Allegation: Staff did not provide proper medication assistance to resident in care. – Unsubstantiated. According to complainant, R1 became a resident at Brookdale Folsom in the memory care unit in August 2022. On three occasions R1 was found over medicated that R1 was barely breathing and was unable to walk, talk, eat, or drink. Complainant concerns is that staff were giving R1 narcotics such as Morphine with no clear idea of drug indications and side effects. The Department requested and reviewed R1’s physician’s report. Physician’s report indicates R1 is unable to administer own prescription medications, administer own injections, perform own glucose testing, administer own PRN medications, administer own oxygen, and store own medications. R1 is on hospice. According to R1’s doctor’s orders, R1 was prescribed Morphine Sulfate oral solution 10 MG/ML to give R1 0.5 ml by mouth every 1 hours as needed for pain/sob. The Department interviewed a total of six (6) staff. Interview statements received from staff (S1) indicated, R1 is on hospice and was prescribed Morphine for pain. S1 stated facility’s procedure before providing R1 with Morphine, the facility would call and notify R1’s responsible party (RP) to get an approval. The facility will not provide Morphine without calling hospice for their advice and recommendations. Interview statement received from Resident Care Director (RCD) indicated, the facility was in constant communication with R1’s RP regarding medications such as Morphine. RCD stated when R1 was placed on hospice R1 will clearly notify staff that they were having back and hip pain. R1 was starting to decline, and staff would often hear R1 groaning in pain and would continuously shift positions to indicate she was in pain or uncomfortable. Interview statement received from S3 and S4 indicated, R1 is not able to request for specific medication, however, R1 is able to notify staff that R1 is in pain. After R1 would notify staff of their pain, staff would then notify Med Techs. The Department received interview statement from R1’s hospice nurse. Hospice nurse indicated, R1 can request for Morphine sometimes. R1 was able to make R1’s needs known. Hospice nurse explained that the facility would give R1 Morphine in the middle of the night and then R1 would subsequently be out of it the next morning. Hospice nurse stated they were not there when the facility medicated R1. The facility has given R1 morphine due to shortness of breath or for pain. Hospice nurse indicated there is not a lot of times that R1 was in pain that the nurse knew of. Hospice nurse indicated, the facility is required to notify R1’s RP and hospice when giving Morphine to R1. The Department reviewed R1’s medication lists and the MAR. Facility is correctly using the MAR and found no discrepancies. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Resident sustained multiple falls while in care. – Unsubstantiated. According to complainant, during R1’s stay at the facility R1 experienced at least 6 falls causing physical and emotional trauma which accelerated R1’s existing Dementia. The last fall occurred because an aid left R1 unattended on the toilet resulting in R1 falling forward onto R1’s forehead and arms. According to R1’s physician’s report that was completed on 7/15/2022, R1 can bathe self, dress/groom self, feed self, and care for own toileting needs. R1 is ambulatory. According to R1’s service plan completed on 9/14/2022, R1 can perform the following showering tasks with physical assistance as needed, washing lower body. R1’s showers schedules are on Monday and Thursday. R1 needs help in the bathroom with pulling pants up and down, assist with handling toilet paper and wiping from front to back. Assist with changing protective undergarments. R1 is incontinence of bladder. Manage R1’s incontinence product. Facility is to provide physical assistance to and from the dining room and or community activities as needed. R1 has falling in the last 12 months. R1 uses a walker as mobility aid. According to R1’s progress notes, R1 had a total of six (6) unwitnessed falls. All unwitnessed falls were reported to R1’s RP. R1 was sent out to the hospital for an evaluation. The facility notified R1’s hospice nurse of all unwitnessed falls. Interview statement received from R1’ hospice nurse indicated, R1 was able to walk and talk at the beginning and had declined significantly. Hospice nurse stated they were not there to observe any of R1’s fall incidents that occurred at the facility. Interview statement received from S3 indicated, R1 is a fall risk. R1 had multiple falls. The facility had implemented a fall plan for R1. Staff is to conduct rounds to check on R1 every 30 minutes. S3 stated when a resident in the memory care unit has an unwitnessed fall the facility will call 911. EMT would come out to assess resident and check vitals. EMT will then transfer resident to the hospital for an evaluation. The facility will then call resident’s responsible party to notify them of the incident. S3 explained if a hospice resident had a fall the facility will call and notify hospice. Hospice will then send their nurses out to evaluate the resident. According to R1’s progress notes, all unwitnessed falls were reported. The facility did their due diligence after each unwitnessed fall. R1 was sent out to the hospital for an evaluation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff left resident unattended. – Unsubstantiated. According to complainant, an aid left R1 unattended on the toileting resulting in a fall. Interview statement received from ED indicated, a staff was assisting R1 in the bathroom and an exit door alarm went on. R1’s bedroom is located near the exit door. Staff went to check if there were any residents that tried to leave the community and returned to assist R1 in less than a minute. ED stated when staff returned R1 was still on the toilet and there was no fall incident when that occurred. Interview statement received from 5 staff indicated R1 is a fall risk and staff are to conduct frequent rounds to check on R1. Interview with 5 staff indicated, they were not working when this incident occurred and was not aware of that incident at all. Interview received from R1’s hospice nurse indicated, during visits there are always staff there with residents in the memory care unit. 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.

On 07/26/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director, Kristine Clawson, and explained the purpose of the visit. At 9:50 AM, LPA 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, and kitchen. 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 one (1) week and perishable foods for a minimum of two (2) days. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 06/15/2023. LPA observed medications to be locked and inaccessible to residents in care. At 10:40 AM, LPA reviewed a total of five (5) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for four (4) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of five (5) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision. No deficiencies being cited during today's inspection. Exit interview conducted and report provided.