<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700174
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:00:18 PM


Document Has Been Signed on 05/04/2023 02:00 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 58DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Faith BrownTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday May 4, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (6) and staff (5) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills. Additionally, LPA reviewed elopement drills and training for the evacuation chair.

LPA and Senior Building Services Director Clayton Fowler toured the facility together to ensure the health and safety of residents in care. The areas toured included memory care apartments, assisted living apartments, lobby, kitchen, laundry rooms, and wellness center. LPA observed the facility's emergency food and water storage and PPE storage. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPA requested the facility to update their LIC500, LIC610E and current liability insurance and submit to the Department by 5/18/2023.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1