347005467-8-27-2026-59-AS-LMUZ-DXQUPF-20260908154527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005467
Report Date: 08/27/2026
Date Signed: 08/27/2026 02:32:10 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
05/26/2026 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260526143632

FACILITY NAME:	BROOKDALE FOLSOM		FACILITY NUMBER:	347005467
ADMINISTRATOR:	SHARI KRANIG		FACILITY TYPE:	740
ADDRESS:	780 HARRINGTON WAY		TELEPHONE:	(916) 983-9300
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	130	CENSUS:	DATE:	08/27/2026
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Shari Kranig, Executive Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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-Due to lack of supervision, resident was on the floor for an extended period of time
-Staff neglect resulted in resident being hospitalized
-Staff did not notify authorized representative of change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Shari Kranig, to deliver complaint investigation findings regarding the above stated allegations.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.
According to resident (R1’s) Personal Service Plan, dated September 9, 2025, R1 self-managed their own medications, including self-administering, ordering, coordinating, and safe storage. R1 did not require assistance with dressing, grooming, toileting, and was independent going to dining room or community activities. R1 was able to shampoo their hair and wash their body with staff physical assistance as needed. R1 received showers twice per week. R1’s shower logs indicated that they received a shower on January 29, 2026 and no skin issues were observed. R1’s shower logs indicated that they refused a shower on February 2, 2026. Interviews with staff (S1, S2, S3, and S4) indicated that R1 was independent and was not considered a fall risk.
**********************************************Continued on LIC9099-C***************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026

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 4

Control Number 59-AS-20260526143632

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: 08/27/2026

NARRATIVE

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R1’s Progress Notes and staff interviews indicated that, on January 31, 2026, R1 was escorted back to their room from the dining room due to weakness. Progress Notes indicated that R1 stated that their daughter will deliver some medication for their cold. Additional notes from January 31, 2026 indicated that staff had checked on R1 a few times throughout the evening and R1 stated that their family had brought them medication. Staff indicated that they advised R1 that, if they need anything, to let them know. Progress Notes from February 1, 2026 indicated that staff checked on R1 and that R1 indicated that they were alright and taking their medication. Staff advised R1 to drink lots of fluids. Progress Notes from February 2, 2026 indicated that staff checked on R1 throughout their shift. R1 had informed staff that they were feeling much better. R1 still had a cough and congestion, however, were feeling much better. Progress Notes from February 3, 2026 indicated that S4 tested R1 for Influenza A and B and COVID. R1 tested positive for Influenza A. The facility implemented their infection control plan. S4 indicated that R1’s responsible party was contacted and that both R1 and R1’s responsible party were thankful and appreciative of the help provided.

Interviews with S1, S2, S3, and S4 indicated that, throughout the timeframe that R1 was ill, January 31, 2026-February 3, 2026, staff were checking on R1, food and drinks were being delivered to their room, R1’s garbage was being removed, and R1’s bed was being made. Staff interviews indicated that they did not observe R1 not eating or drinking. Progress Notes dated February 4, 2026 and interviews with S1, S2, and S3 indicated that, on February 4, 2026, R1 was found on the floor around 8:00am. S1, S2, and S3 indicated that the AM shift begins at 6am. Upon arrival, the AM staff meet with the NOC shift staff so night staff can report any observations made during their shift. S1 indicated that NOC shift makes their last rounds checking on residents around 5:30am. S3 indicated that, on February 4, 2026, the NOC shift did not report any changes to R1’s condition. S1 and S3 indicated that the AM shift begins their rounds checking on residents around 6:15am. S3 indicated that, when they checked on R1, they observed R1 in their recliner. S2 and S3 indicated that, around 8am, they were in the same hallway as R1’s room. S2 was providing medication to a resident near R1’s room and S3 opened R1’s door and observed R1 on the floor. S3 went to assess R1 and S2 joined them after they administered the other resident’s medication. S2 had made contact with S1 who was assisting a resident in the facility experiencing a medical emergency. S1, S2, and S3 indicated that emergency medical services (EMS) and the fire chief were already in the building when R1 was found. S1 and S2 spoke with EMS and the fire chief to also check R1. S2 indicated that they called R1’s responsible party via phone and were in communication with them throughout the incident. Staff indicated
************************************************Continued on LIC9099-C***************************************************

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20260526143632

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: 08/27/2026

NARRATIVE

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that R1’s responsible party also spoke with EMS. R1’s progress notes indicated that there were no physical signs of head injury and there were no signs of skin injury as a result of the fall. Notes also indicated that R1’s responsible party and health care provider were contacted.

EMS records indicated that they were notified on February 4, 2026 at 7:58am regarding R1. EMS began their assessment of R1 at 8:03am. Records indicated that R1 was sitting on their walker. R1 were fully awake, fully oriented, and neurologically intact at the time of assessment, however, seemed lethargic at times. R1 had been found on the floor of their room by staff in the morning and it is unclear how long they had been on the ground. R1 did not recollect falling or how they got on the ground. R1 had no outward signs of trauma and no complaints regarding their head, neck, or back. R1 denied any dizziness, weakness, chest pain, shortness of breath, nausea, vomiting, cough, fever, or any other flu-like symptoms. R1 was negative on the stroke scale and blood sugar was normal. All other vitals were normal. R1 was able to stand and pivot to the gurney with assistance. Lastly, R1 experienced no acute changes in route to the hospital.

Hospital records indicated that R1 was admitted on February 4, 2026 due to being “found down”. The hospital course indicated that R1 had a history of hypothyroid, prior CVA, seizure disorder, cognitive impairment, and history of breast cancer presenting after they were found down. R1 was treated for community-acquired pneumonia and mild dehydration. R1 was quickly weaned off oxygen and improved with antibiotics. Throughout their admission they frequently voiced passive thoughts of death although they denied any depressions and any active suicidal ideations. They were very clear in their DNR/DNI code status but at this time did not appear to have any criteria for hospice. They were sent to skilled nursing facility in stable condition. Their family was involved and frequently updated. Additional notations from hospital records indicated that, on February 5, 2026, R1’s skin was assessed. R1 was observed to have a stage 1 pressure injury measuring 1.0x0.4cm as evidenced by non-blanchable redness, a deep tissue injury/unstageable pressure injury on buttocks measuring 10.0x9.0cm as evidenced by dark red/purple discoloration and slough noted, and a deep pressure injury on their right ischial lower buttock measuring 1.5x0.6cm as evidenced by dark red/purple discoloration. R1 was discharged from the hospital on February 7, 2026 to the skilled nursing facility. Interviews with skilled professionals indicated that wounds such as R1’s could occur within hours.

**********************************************Continued on LIC9099-C****************************************************

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20260526143632

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: 08/27/2026

NARRATIVE

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According to R1’s progress notes and interviews with S1, S2, S3, and S4, the facility was in communication with R1’s responsible party throughout their change in condition beginning January 31, 2026-February 4, 2026, when they were sent to the hospital. On February 5, 2026, CCLD received an Unusual Incident/Injury Report LIC624 indicating that, on February 4, 2026, R1 was found on the floor in their apartment at around 8am and was transported to the hospital. The LIC624 also indicated that the facility notified R1’s responsible party.

Based on interviews conducted and documentation obtained, 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: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026

LIC9099 (FAS) - (06/04)

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