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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001843
Report Date: 10/30/2020
Date Signed: 10/30/2020 01:47:59 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:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:SHERRIE KUARFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 21DATE:
10/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sherrie KuarTIME COMPLETED:
11:00 AM
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On October 30, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Administrator, Sherrie Kuar, via telephone to conduct an unannounced Case Management visit. This visit was conducted via telephone due to COVID-19 and pre-cautionary measures.

The purpose of the telephone call was to follow-up on an Unusual Incident/ Injury Report that was sent to Community Care Licensing (CCL) on 10/08/2020. The report indicated that a resident (R1) had shortness of breath and was unresponsive. R1 was transferred to Sutter Emergency Room for further medical evaluation.

LPA interviewed Sherrie regarding the report. The interview with Sherrie indicated that R1 was in the process of hospice initiation due to changes in health conditions. R1 was transferred to Sutter Emergency Room on three different occasion and R1's health was declining. LPA requested for R1's physician report and discharge medical documents.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the administrator was advised that a signed copy of this report shall be emailed to LPA.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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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