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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001404
Report Date: 12/11/2023
Date Signed: 12/11/2023 10:02:45 AM


Document Has Been Signed on 12/11/2023 10:02 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: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:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marivel JacobsonTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday December 11, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (3) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Parks and Administrator Marivel toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

First aid kit was fully stocked. Facility was clean and well organized. Facility was current on fire drills. All required posting were observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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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