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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001404
Report Date: 01/10/2023
Date Signed: 01/10/2023 10:30:44 AM


Document Has Been Signed on 01/10/2023 10:30 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BROOKVIEW RCFE, INC.FACILITY NUMBER:
315001404
ADMINISTRATOR:JACOBSON, MARIVELFACILITY TYPE:
740
ADDRESS:2061 BUTTERFIELD LANETELEPHONE:
(916) 966-9370
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 3DATE:
01/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria AlbertoTIME COMPLETED:
11:00 AM
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LPA Parks arrived on Tuesday January 10, 2023 to conduct the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA and staff Maria toured the facility together to ensure health and safety of residents in care.

LPA and Administrator (via phone) completed the infection control domain together and facility was found to be in substantial compliance at this time.

LPA requested updated copies of LIC500, LIC610, and current liability insurance to be faxed to LPA by end of the month.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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