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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700251
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:43:19 PM


Document Has Been Signed on 10/19/2023 04:43 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:
10/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ramona McGillTIME COMPLETED:
05:00 PM
NARRATIVE
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On 10/19/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator.

On 10/10/23, LPA Mknelly delivered complaint findings to the facility.
At the time of the visit, caregiver S1 was at the home and providing resident care and supervision. The Administrator was away from the facility at the time, leaving S1 as the sole caregiver.
Following the visit, LPA checked for S1’s criminal background clearance and association to the facility and found that S1 had not been cleared.
Communication with the administrator also found that S1 did not have required health screening nor training.

As a result of this incident, 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.

Civil penalties are also issued.

Report reviewed. Copy of report and appeal rights provided
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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 10/19/2023 04:43 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance. (e )All individuals subject to a criminal record review …shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ...This requirement was not met based records and statements.
This posed a risk to residents.
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Staff are not working until clearance is approved.
Licensee will submit a backup staffing plan and new LIC 500 by the POC date of 10/26
Type B
11/02/2023
Section Cited
CCR
87412(a)

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Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met based on statements and records. This posed a potential risk
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Licensee will submit a statement of understanding and intent to follow this requirement by the POC date of 11/2/23.

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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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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