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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700174
Report Date: 06/16/2022
Date Signed: 06/16/2022 12:35:28 PM


Document Has Been Signed on 06/16/2022 12:35 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 50DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Clayton Fowler, Senior Building Services DirectorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 6/16/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Senior Building Services Director (SBSD), Clayton Fowler, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA were screened by staff upon entry.

LPA spoke to the Administrator, Kristie Laine, by phone and Administrator stated that SBSD can sign report.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, resident apartments, dining room, kitchen, outdoor area, lobby, laundry rooms, staff break room, and common restrooms. Fire extinguishers are ready for emergency use and all stairwells have evacuation chairs. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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