312700251-10-10-2023-59-AS-MSEY-CWNPAS-20231016110909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700251
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:46:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2023 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20230905104828

FACILITY NAME:	BROOKFIELD HOME CARE		FACILITY NUMBER:	312700251
ADMINISTRATOR:	MCGILL, RAMONA		FACILITY TYPE:	740
ADDRESS:	5342 BROOKFIELD CIRCLE		TELEPHONE:	(916) 415-1012
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	6	CENSUS: 4	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	caregiver		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff slapped resident
Staff neglecting resident

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230905104828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKFIELD HOME CARE	FACILITY NUMBER: 312700251
	VISIT DATE: 10/10/2023

NARRATIVE

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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.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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