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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 01/13/2026
Date Signed: 01/13/2026 05:12:57 PM

Substantiated


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
10/23/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20251023095816
FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:SHARI KRANIGFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 87DATE:
01/13/2026
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Shari Kranig, Executive DirectorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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-Staff are mismanaging residents' medications
-Staff were not checking resident's blood pressure resulting in hospitalization
-Staff did no ensure resident had water resulting in dehydration
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Sheri Kranig, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, LPA conducted a medication count, conducted interviews, and obtained documentation pertinent to the investigation.

Allegation: Staff are mismanaging residents' medications
On October 24, 2025, LPA conducted a medication count for residents (R2 and R3), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed two (2) medications for R2 that were over the amount documented. LPA observed one (1) medication for R3 that was over the amount documented.

*******************************************Continued on LIC9099-C**************************************************
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 59-AS-20251023095816
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 01/13/2026
NARRATIVE
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20251023095816
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:


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Facility agrees to conduct an in-service training with Med-Techs on medication administration and the importance of accurate documentation. Facility will also begin conducting medication audits to ensure there are no errors.
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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.
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Facility will submit information regarding in-service training and medication audit, including time and date of in-service and training material, to LPA by POC due date of 1/14/26.

Facility requested an extension for 1/23/26.
Type A
01/14/2026
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by:
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Facility agrees to conduct an in-service training with staff regarding observation of residents. Facility will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 1/14/26.
Facility requested an extension for 1/23/26.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20251023095816
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Facility agrees to submit a statement of understanding as well as conduct a staff training to ensure staff understand the caregiver expectations. Facility will also submit a list of all staff who attended the training by the POC due date of 1/14/26.
Facility requested an extension for 1/23/26.
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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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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
10/23/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20251023095816

FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:SHARI KRANIGFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 87DATE:
01/13/2026
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Shari Kranig, Executive DirectorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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-Staff did not immediately notify resident's authorized representative of incidents
-Staff are not meeting resident's dietary needs
-Staff did not ensure resident had privacy during visits
-Staff did not ensure dishes were cleaned and sanitized
-Staff did not ensure resident had access to a telephone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Sheri Kranig, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.
Allegation: Staff did not immediately notify resident’s authorized representative of incidents
Resident (R1’s) responsible party indicated that the facility was to contact them anytime R1 was not feeling well, which was not done. R1’s responsible party indicated that R1 was sent to the hospital in April 2025. According to Unusual Incident/Injury Report LIC624, R1 was sent to the hospital on April 18, 2025, due to severe headache. LIC624 indicated that the facility contacted R1’s responsible party. Facility staff indicated that R1 only had one incident on April 18, 2025 and that R1’s responsible party was notified.
*********************************************Continued on LIC9099-C**************************************************

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20251023095816
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 01/13/2026
NARRATIVE
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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*********************************************
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20251023095816
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: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467
VISIT DATE: 01/13/2026
NARRATIVE
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7