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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700019
Report Date: 10/26/2020
Date Signed: 10/26/2020 11:29:41 AM

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: 125DATE:
10/26/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jasmine RidenourTIME COMPLETED:
11:30 AM
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
On October 26, 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 10/05/2020. The report indicates that a resident (R1) was found on the floor bleeding profusely from left foot cuff and was sent to the ER for a medical evaluation.

LPA interviewed Jasmine regarding the report. The interview with Jasmine indicates that R1 has not returned to the community. Jasmine stated R1 is awaiting for a surgery procedure. R1's responsible party had been notified of the incident. LPA requested for R1's physician report, needs and services plan, and discharge medical documents when R1 returns to the community.

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: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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