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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001843
Report Date: 03/25/2021
Date Signed: 03/25/2021 10:29:51 AM

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:
03/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sherrie KuarTIME COMPLETED:
10:15 AM
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On March 25, 2021 at 10 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility and spoke with Executive Director (ED), Sherrie Kuar, via telephone to conduct an unannounced Case Management- Incident to obtain additional information regarding an incident that occurred on 03/16/2021. 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 Report that was submitted to Community Care Licensing (CCL) on 03/22/2021. This report indicted memory care resident (R1) informed Medication Technician that another memory care resident (R2) has been going into R1's room and touching R1 inappropriately.

LPA interviewed Sherrie Kuar regarding the incident report. The interview with Sherrie indicated that Law Enforcement were called and a police report was made. Ombudsman was notified. Skin Check was conducted with no noted injuries, bruising, or discoloration was noted. R1's Primary Care Physician was informed of the incident and had provided new medication orders for resident's paranoia and hallucination. Both resident's responsible party were notified. The facility had submitted SOC 341 along with an incident report. LPA requested for R1 and R2's physician report.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility. Sherrie Kuar was advised that a signed copy of the 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: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
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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