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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700137
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:46:20 PM


Document Has Been Signed on 06/27/2022 12:46 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:BROADWAY SENIOR LIVING INCFACILITY NUMBER:
312700137
ADMINISTRATOR:ALLISON, THOMAS RFACILITY TYPE:
740
ADDRESS:708 DARLING WAYTELEPHONE:
(916) 832-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Liz PerezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 6/6/22 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.
Staff notified LPA that five of six residents in care have tested covid positive in the past week. No staff have yet tested positive.
LPA exited the facility and called Administrator, Tom Allison. LPA will follow-up with an email with reporting and quarantine resources.
The annual inspection is postponed at this time.
As a result of this visit, no deficiencies were observed.

LPA Mknelly returned to complete the visit on 6/27/22. Covid procedures followed. Administrator, Thomas Allison arrived to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BROADWAY SENIOR LIVING INC
FACILITY NUMBER: 312700137
VISIT DATE: 06/27/2022
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licensees followed the infection control domain guidelines and facility was found to be in substantial compliance at this time.

LPA advised: More detailed symptom screening for visitors, staff and residents be recorded, regularly evaluate that chemicals are inaccessible to residents, regularly monitor that Hot water remains 105-120' F., Verify that all caregivers are associated (may use the Guardian site) and plants be trimmed to keep walkways clear.

Licensee will submit copy of liability insurance certificate, LIC 500, LIC 9020- Resident roster.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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