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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700174
Report Date: 05/15/2024
Date Signed: 05/15/2024 12:16:37 PM


Document Has Been Signed on 05/15/2024 12:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:BRUNSWICK VILLAGEFACILITY NUMBER:
292700174
ADMINISTRATOR:LAINE, KRISTIEFACILITY TYPE:
740
ADDRESS:316 OLYMPIA PARK CIRCLETELEPHONE:
(530) 274-1992
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:100CENSUS: 56DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kristie LaineTIME COMPLETED:
12:20 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Clayton Fowler, Maintenance Director. This facility has 56 bedrooms. There is one one-bedroom apartment with a full bathroom and the rest are studio apartments with full bathrooms; some shared and some private. There is a memory care unit that has 12 rooms; some shared and some private. The memory care unit has a sitting area and dining area and a locked medication cart. The memory care unit is also secured with a delayed egress system. There is a courtyard in the middle of the facility building. The first floor has the kitchen and dining area, offices for administration, and a couple of common areas. The second floor has a common area, beauty shop, and the medication room. There is also a courtyard to the left of the main entrance side of the building. Several rooms were toured. Several resident records and staff training records were reviewed.

A few topics were discussed.


The following shall be updated and submitted to Licensing by June 1 2024:
-LIC 500- facility personnel or staff schedule
-LIC 308- designation of administrative responsibility. (who is in charge when administrator is not present.)
- copy of liability insurance

No deficiencies cited during this visit.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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