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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700019
Report Date: 07/17/2020
Date Signed: 07/17/2020 02:55:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TERRACES OF ROSEVILLE, THEFACILITY NUMBER:
312700019
ADMINISTRATOR:JASMINE RIDENOURFACILITY TYPE:
740
ADDRESS:707 SUNRISE AVETELEPHONE:
(916) 786-3277
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:199CENSUS: 167DATE:
07/17/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Jasmine RidenourTIME COMPLETED:
03:00 PM
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On July 17, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Executive Director, Jasmine Ridenour, via telephone to conduct an unannounced Case Management visit. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 6/29/2020. The report indicates that a resident (R1) was found on the floor and was sent to the ER for a medical evaluation. R1 was discharged to a Skilled Nursing Facility where R1 is receiving treatment.

LPA interviewed Jasmine regarding the report. The interview with Jasmine indicates that R1 will be returning to the community today. LPA requested for R1's physician report, needs and services plan, and discharge medical documents.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Executive Director was advised that a signed copy of this report shall be emailed to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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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