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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700251
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:45:45 PM


Document Has Been Signed on 10/10/2023 02:45 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:BROOKFIELD HOME CAREFACILITY NUMBER:
312700251
ADMINISTRATOR:MCGILL, RAMONAFACILITY TYPE:
740
ADDRESS:5342 BROOKFIELD CIRCLETELEPHONE:
(916) 415-1012
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:caregiverTIME COMPLETED:
03:00 PM
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 On 10/10/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver . Administrator spoke by phone and is unavailable to attend.
On 9/27/23, licensee provided a statement that on 9/4/23, some time after midnight, R1 left the facility unassisted and walked to a neighbor’s yard. Facility staff (S2) was working on the overnight of 9/4/23. S2 had reportedly used the restroom and when they returned to the common area, S2 saw the front door open and that R1 had gone outside. Licensee also reported that the alarm to the front door was inoperable. Also on 9/27/23, LPA observed that the door alarm had not yet been repaired.
At the time of the 9/4/23 incident R1 had a prescription for medication as needed for sleep. 8/28/23- 9/2/23, facility records show that R1 was given the medication daily for sleep. However, records did not show R1 having received the medication.
The facility’s plan of operations states that all exterior doors have an operational bell/buzzer or other auditory device to alert staff when the door is opened.
LPA and licensee reviewed reporting requirements related to other incidents in which R1 was involved.
As a result of the investigation, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided to designee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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 10/10/2023 02:45 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: BROOKFIELD HOME CARE
FACILITY NUMBER: 312700251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2023
Section Cited
HSC
1569.312(d)

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Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, ...
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Licensee has repaired the existing door alarms.
Licensee will submit the plan to upgrade their door alarms and additional measures for overnight supervision to ccl by the POC date of 10/24/23.
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This requirement was not met based on statements and observation that R1 had known overnight sleeplessness and that R1 was able to leave unobserved.
This posed an immediate risk to R1.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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