Brookdale Folsom.
A large home, reviewed on public record.
Compared to 84 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
Citation history, plotted month by month.
7 deficiencies on record. Each bar is a month with a citation.
Finding distribution
7 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Brookdale Folsom's record and state requirements.
The facility has 12 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
17 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The most recent inspection occurred on January 13, 2026 — can you provide families with a copy of the deficiency notice from that visit and walk through the corrective actions implemented for each cited item?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
17 inspections in the public record, most recent first. Plain-language summaries open first — click into any row for the full citation text.
2026-07-01Annual Compliance VisitNo findings
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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.
2026-01-13Other VisitType A · 3 findings
Plain-language summary
This facility received an inspection investigating multiple allegations about care for one resident who was hospitalized with low blood pressure and dehydration in early October 2025. Inspectors found that staff failed to monitor the resident's blood pressure as required by their care plan and did not ensure adequate water intake, which contributed to the resident's hospitalization; the hospital diagnosed the resident with low blood pressure likely caused by dehydration and medication interactions. The other allegations—about dietary needs, meal sanitation, visit privacy, and phone access—were found to have no evidence of violation.
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“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.”
“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.”
“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.”
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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. 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 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********************************************* 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 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.
2025-12-18Annual Compliance VisitNo findings
2025-07-25Other VisitNo findings
Plain-language summary
This was the facility's required annual inspection, conducted without advance notice. The inspector found the facility clean and well-maintained, with proper hot water temperatures, current medication records, trained staff, and working safety equipment including fire extinguishers and evacuation chairs; no violations were identified.
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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.
2025-04-03Other VisitNo findings
Plain-language summary
On March 11, 2025, a resident in memory care exited the facility through the main door by following staff out, when the alarm door did not close completely behind them; a staff member on break in the parking lot immediately saw the resident and brought them back inside with no injuries. The facility reviewed its elopement prevention policy with staff, tested the alarm doors to confirm they were working properly, and conducted training on elopement risks and response procedures. No violations were found during this follow-up visit.
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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.
2024-09-18Other VisitNo findings
Plain-language summary
A licensing analyst visited the facility on September 18, 2024, to investigate an unusual incident report after a resident reported being physically and sexually abused by staff on the night of September 15th. The facility's internal investigation found the allegations unsubstantiated, and staff records showed the accused employee was not scheduled to work and was not present that night; the resident's report occurred after watching crime-related television programs, which the responsible party then removed. The resident was later diagnosed with a urinary tract infection, which can cause confusion and changes in thinking in older adults, and the facility is monitoring the resident's condition and coordinating care with the responsible party; no violations were found during the inspection.
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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.
2024-08-07Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that a staff member was under the influence of drugs or alcohol while working. The facility's records showed no concerns about this staff member, and when interviewed, the staff member denied the allegation. The investigator found insufficient evidence to substantiate the complaint.
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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.
2024-07-22Complaint InvestigationSubstantiatedType A · 2 findings
Plain-language summary
A complaint investigation found that staff left this resident in soiled briefs for extended periods, sometimes up to four hours, despite checking schedules that called for changes every two hours. While the resident was resistant to care and sometimes combative during diaper changes, hospice records documented multiple instances between February and April 2024 when the resident was found in saturated diapers, and staff did not consistently put on compression stockings or change soiled clothing daily as prescribed. The facility's failure to meet these care needs was substantiated, though staff faced genuine challenges managing the resident's behavioral resistance to personal care.
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“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.”
“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.”
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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... 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 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.. 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 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.. 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 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... 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 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 com
2024-07-18Other VisitNo findings
Plain-language summary
On July 4, 2024, a resident with dementia who regularly wanders in the courtyard was found in distress with sweating and labored breathing during hot weather; staff responded with emergency protocols, though staff could not recall the exact time of the last check before the incident was discovered. A follow-up inspection on July 18, 2024 found no violations, and the facility has since installed door alarms on the courtyard to alert staff when residents go outside during periods of excessive heat. No deficiencies were cited.
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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.
2024-06-20Annual Compliance VisitNo findings
Plain-language summary
A routine annual inspection was conducted on June 20, 2024, with no violations found. The inspector checked the facility's bedrooms, bathrooms, kitchen, and common areas and confirmed that living spaces were clean and well-maintained, food was properly stored, emergency equipment was functional, and safety hazards were absent. Staff and resident files were also reviewed.
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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.
2024-06-13Other VisitNo findings
Plain-language summary
A state inspector made an unannounced visit on June 13, 2024, to conduct the facility's required annual inspection, reviewing resident and staff files. No violations were found during this visit. The inspector plans to return at a later time to complete the full annual inspection.
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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.
2024-04-25Other VisitType A · 1 finding
Plain-language summary
On April 25, 2024, the state visited the facility to investigate an incident from April 11 when a resident receiving hospice care left the facility unassisted and was found at a coffee shop down the street; police returned the resident safely with no injuries reported. The facility's own medical documentation indicated this resident was unable to leave without assistance. The state cited the facility for inadequate supervision and noted the facility conducted staff training on preventing residents from leaving unsupervised after the incident occurred.
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“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.”
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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.
2024-03-06Complaint InvestigationSubstantiatedType A · 1 finding
Plain-language summary
A complaint investigation found that the facility's medication counts did not match its records: one resident had more of a medication than documented, four medications were in short supply, another resident had five medications in excess, and a third resident had two medications over the documented amount. The investigation also found that a new blood pressure medication for one resident was delayed by a week before it was dispensed, though the resident continued taking a discontinued medication during the delay. These medication management issues were substantiated as violations.
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“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.”
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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.
2024-02-21Complaint InvestigationNo findings
2024-01-29Other VisitNo findings
Plain-language summary
On January 29, 2024, state licensing staff conducted a follow-up visit to review a report filed in December 2023 after a resident reported that a staff member was rough with them. The facility immediately suspended the staff member, prevented further contact with the resident, notified police, and conducted an internal investigation that found no abuse occurred; the staff member was terminated on December 14, 2023 for other performance issues. No violations were cited.
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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.
2024-01-12Annual Compliance VisitNo findings
Plain-language summary
A state inspector made an unannounced visit on January 12, 2024, to investigate a complaint received on January 9, 2024. The inspector reviewed relevant documentation and interviewed staff, and found no violations.
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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.
2023-10-04Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
The facility received a complaint about one resident striking another during a bedtime assistance incident in July 2023. Staff were present at the time and intervened immediately, and the investigation found no evidence that the facility failed to adequately supervise the residents or provide proper care. No violations were cited.
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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.
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