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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001843
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:32:16 PM


Document Has Been Signed on 11/29/2023 03:32 PM - 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:JANELLE MONIQUE DOUGLASFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 11DATE:
11/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Janelle Monique, Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit in regards to an incident report that was received. LPA met with Administrator, Janelle Douglas, during today's inspection.

CCL received an incident report from the facility stating that during destruction of discontinued medications facility staff observed there was 2 packs of hydrocodone missing from the medication cart. Missing medications belonged to a past resident who no longer resides at the facility. LPA interviewed administrator in which the staff member responsible for medication destruction has been terminated. An internal investigation occurred and the investigation came back inconclusive. LPA reviewed medication policies, and medication destruction policies. Facility has reported missing medications to the local police department. Administrator stated they will be working on new procedures in regards to medication destruction. If changes occur to facility policy and procedures, Administrator agrees to send a copy into CCL for review.

No deficiencies cited during today's inspection. Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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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