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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700641
Report Date: 06/18/2020
Date Signed: 06/18/2020 02:47:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SOMERFORD PLACE-ROSEVILLEFACILITY NUMBER:
312700641
ADMINISTRATOR:TAYLOR, DEBORAHFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(617) 796-8350
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:64CENSUS: 35DATE:
06/18/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Deborah TaylorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to commence a Case Management via telephone due to COVID-19 and pre-cautionary measures. LPA spoke to Deborah Taylor, administrator, and stated the purpose of the call.

On 6/12/2020, the Department received an incident report stating Resident (R1) had an unwitnessed fall and was sent to the hospital for evaluation on 6/7/2020. R1 returned to the community on the same day with a diagnosis of closed head injury (3 stables back of his head).

LPA Keosavang requested a copy of R1's Plan of Care, Physician’s Report, and discharge medical records.

No deficiencies are being cited.

An exit interview was conducted with Deborah Taylor, Administrator, via telephone. A copy of this report will be provided to the facility via Email. The report is to be signed and returned to LPA via Email.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020
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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