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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700174
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:38:21 PM


Document Has Been Signed on 04/25/2024 02:38 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:
04/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kristie LaineTIME COMPLETED:
02:45 PM
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LPA Hiratsuka observed during an investigation the licensee changed the dates of the annual rate increase from the anniversary date to the beginning of the year and did not have signed agreements from the residents stating that everyone is in agreement with the change of date for the annual fee.

Title 22 Regulation Admission Agreements 87057(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

The admission agreement for one of the residents that was signed in 2017 states "to cover annual operating, maintenance, insurance, and other cost increases, you can expect an annual increase in Basic Rent and the Services Rate on the 12 month anniversary date of this agreement."

The licensee did do the proper increase in annual fees by giving a 60 day notice as required, but did not get the signed modification date change for the increase itself.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights were provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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Document Has Been Signed on 04/25/2024 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: BRUNSWICK VILLAGE
FACILITY NUMBER: 292700174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2024
Section Cited
CCR
87057(d)

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Admission Agreement. The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications.
This requirement was not met as evidenced by:
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By 05/25/2024, the licensee shall come up with a written agreement stating how they shall ensure the regulation and submit it to Community Care Licensing Division.
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Based on resident file records review, Licensee did modified the date of raising the annual fee without having a written agreement to it which poses a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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