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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001843
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:32:04 AM


Document Has Been Signed on 05/12/2022 10:32 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 17DATE:
05/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Regional Nurse Robyn MooreTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident visit. LPA met with Resident Care Coordinator (RCC), Juan Ramirez, and explained the purpose of the visit. Prior to entering the facility, the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. Regional Nurse, Robyn Moore, arrived at a later time.

The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 05/11/2022. The report indicates that a memory care resident (R1) made an allegation of physical abuse by husband. The report also indicates that on 05/05/2022 R1 made an statement to facility staff of a sexual assault occurred.

LPA interviewed Regional Nurse regarding the report. The interview with Regional Nurse indicates that R1 had moved in the facility for a couple months. The facility notified R1's POA, Primary Care Physician, Ombudsman and Police Department. Skin check was performed. No bruises or new skin alterations noted. The facility are conducting an internal investigation and care plan will be updated to include that no male staff to personally care for R1. The facility plans to retrain staff regarding mandated reporting started on 05/11/2022 to be completed by 5/13/2022. LPA requested for R1's physician report, service plan, updated care plan, and copies of training

LPA toured the facility together with Regional Nurse to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed

At this time, deficiencies are not being cited.

Exit interview conducted and a copy of the 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: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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