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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001843
Report Date: 05/24/2023
Date Signed: 05/24/2023 11:46:30 AM


Document Has Been Signed on 05/24/2023 11:46 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:ROBYN MOOREFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 14DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Acting Executive Director: Jerilyn Purol TIME COMPLETED:
12:00 PM
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On 05/24/2023 at 8:45 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the CARE Inspection Tools. LPA met with Acting Executive Director (AED), Jerilyn Purol, and explained the purpose of the visit.

At 8:50 AM, LPA toured the interior and exterior of the facility together with AED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, medication room, courtyard, and laundry room. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. The hot water temperature was measured in the bathroom at 118 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 04/12/2023. Fire drill was last conducted on 04/17/2023. LPA observed medications to be locked and inaccessible to residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed

At 9:20 AM, LPA reviewed a total of five (5) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for five (5) residents and found no discrepancies. LPA reviewed a total of three (3) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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