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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700641
Report Date: 07/30/2020
Date Signed: 07/30/2020 03:20:12 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: 42DATE:
07/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Deborah Taylor TIME COMPLETED:
03:30 PM
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On July 30, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Administrator, Deborah Taylor, via telephone to obtain additional information regarding an incident that occurred at the facility on 07/03/2020. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an Unusual Incident/Injury Report that was submitted to CCLD. This report indicated that resident (R1) was found on the floor of R1's bedroom. R1 was complaining of hip and back pain. Paramedics assessed R1. R1 complained of dizziness and was transported to the hospital.

LPA interviewed Deborah regarding the report. The interview with Deborah indicates that R1 returned to the community the same day with a diagnosis of Pneumonia. R1 was originally sent to the hospital for an evaluation due to a fall. The facility will continue to monitor R1. LPA requested for R1's physician report and medical discharge documents.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and administrator, Deborah Taylor, was advised that a signed copy of the report shall be emailed to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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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