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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700251
Report Date: 05/26/2021
Date Signed: 05/26/2021 03:22:46 PM

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:BROOKFIELD HOME CAREFACILITY NUMBER:
312700251
ADMINISTRATOR:MCGILL, RAMONAFACILITY TYPE:
740
ADDRESS:5342 BROOKFIELD CIRCLETELEPHONE:
(916) 415-1012
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 5DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ramona McGill, administratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 05/26/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator, Ramona McGill and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by staff upon entry.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of five (5) resident bedrooms, shared resident bathroom, and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.

Administrator to send in updated copy of LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, and current copy of Liability Insurance to Community Care Licensing by 06/02/2021.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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