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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700251
Report Date: 02/06/2024
Date Signed: 02/06/2024 09:39:09 AM


Document Has Been Signed on 02/06/2024 09:39 AM - 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: 3DATE:
02/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christian SmithTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Melissa Parks and Kevin MKnelly arrived on Tuesday February 6, 2024, to conduct a case management visit and met with staff. LPAs spoke with the Administrator on the phone and explained the purpose of the visit.

On January 2, 2024, LPA Parks arrived at the facility to begin a complaint investigation.
At the time of the visit, S1 was at the facility with another staff member. Following the visit, LPA checked for S1’s criminal background clearance and association to the facility and found that S1 was not eligible to work in a licensed facility.


As a result of this incident, the following deficiency was 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 were issued.

Exit interview conducted. A copy of this report and appeal rights were emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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 02/06/2024 09:39 AM - 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: 02/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2024
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 observation.
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Administrator agrees to submit a statement of understanding regarding fingerprint clearance needed before staff are able to begin working at the facility.
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This poses an immediate risk to the health and safety of residents in care.
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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: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2