Inspection visit

complaintMay 23, 2024

LITTLE BROOK CARE HOMELicense 3450030043 citations on this visit

3 citations recorded

Inspector’s narrative

What the inspector wrote

Allegation: Facility staff interfered with resident's right to receive medical care. According to interviews with the Administrator and R1’s responsible party, R1 had a dialysis appointment scheduled 2/8/24. Interviews indicated that R1 goes to dialysis three times per week. Interviews indicated that R1 did not make their appointment on 2/8/24. Interview with the Administrator indicated that R1 did not make their dialysis appointment due to the road being blocked by SMUD for repairs to a power line. Administrator also stated that Regional Transit (RT) was unable to pick up R1 for the appointment due to SMUD blocking the roadway. Interview with SMUD indicated that they were conducting work on a broken pole from 2/4/24-2/8/24 and that tree work was involved as well. SMUD indicated that they have no record of the road being blocked or closed. According to documentation obtained from RT, a driver arrived at the care home on 2/8/24 at 9:49am to pick up R1 and take them to their dialysis appointment. Documentation indicated that the RT driver went to the facility door and was advised by facility staff that R1 was eating and needed more time. The RT driver attempted to call the facility phone and it went straight to voicemail. The RT driver attempted to contact the facility an additional time and left a voice message. Documentation indicated that the RT driver departed the facility at 9:56am. RT notes indicated that staff from the facility kept calling to rebook the trip and, when informed RT could not, staff would hang up. RT noted that they attempted to ask the facility staff if R1 still needed a return trip transport from the dialysis appointment and staff would hang up with no response. Documentation indicated that an RT driver arrived to pick up R1 from their dialysis appointment at 2:42pm, however, R1 was not at the appointment location for pick up. RT staff indicated that R1 has set appointments with RT for transport to and from their dialysis appointments three times per week. Administrator stated that the 2/8/24 dialysis appointment is the only one R1 missed. Based on medication counts, 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. Signature on these forms acknowledges receipt of these documents. Allegation: Facility is not providing resident with diabetic diet Interviews with the Administrator indicated that they grocery shop for the facility either every day or every other day. LPA observed resident (R1’s) diet restrictions posted on the refrigerator. The posting indicated that R1 is on a low sodium, sugar, potassium, and phosphorus diet. The posting also lists all the food items and drinks that R1 should not consume as part of the diet restrictions. Interviews with the Administrator and staff (S1 & S2) indicated that R1 was receiving a diabetic diet while they resided at the care home. Interviews indicated that R1 was provided sugar free and low sodium food. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.

Citations

7 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

1569.683(a)Type B
1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations. (3) Information about the resident's right to file a complaint with the department regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman. This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, the facility did not include required information in R1’s eviction notice prior to serving notice, including housing resources and the resident’s rights to file a complaint with contact information of the nearest community care licensing office and the State Ombudsman, which poses a potential health, safety, and personal rights risk to residents in care.
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87224(2)Type B
87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.This requirement if not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not provide the Department with a written report of R1’s eviction within five (5) days, which poses a potential health, safety, and personal rights risk to residents in care.
87465(a)(1)Type A
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility observed R1’s change in condition and did not seek medical attention timely, which poses an immediate health, safety, and personal rights risk to residents in care.
87465(a)(2)Type A
87465 Incidental Medical and Dental Care (a) A plan for incidental medical(…)shall be developed by each facility. The plan shall encourage routine medical(…)care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical(…)needs. This includes transportation which may be limited to the nearest available medical(…)facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure R1 received transportation services to their dialysis appointment, which poses an immediate health, safety, and personal rights risk to residents in care.
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87465(a)(4)Type A
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: 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.
87468.1(a)(16)Type A
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility interfered with R1’s right to receive dialysis treatment on their scheduled appointment date, which poses an immediate health, safety, and personal rights risk to residents in care.
87466Type A
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: Based on records reviewed and interviews conducted, the facility observed changes in R1’s condition and did not document such changes or bring changes to the attention of R1’s physician or responsible party, which poses an immediate health, safety, and personal rights risk to residents in care.
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FAQ · About this visit

Common questions about this visit

What happened during the May 23, 2024 inspection of LITTLE BROOK CARE HOME?

This was a complaint inspection of LITTLE BROOK CARE HOME on May 23, 2024. 3 citations were issued: 3 Type A (serious).

Were any citations issued to LITTLE BROOK CARE HOME on May 23, 2024?

Yes, 3 citations were issued (3 Type A, 0 Type B). The first citation was for: "1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable reg..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·May 23, 2024