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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005468
Report Date: 08/18/2022
Date Signed: 08/19/2022 02:12:06 PM


Document Has Been Signed on 08/19/2022 02:12 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BROOKDALE AUBURNFACILITY NUMBER:
317005468
ADMINISTRATOR:MORGAN WHINERYFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: 61DATE:
08/18/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Morgan WhineryTIME COMPLETED:
03:00 PM
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On this date, LPA Tryon and LPA Muscan visited the facility unannounced to deliver an immediate exclusion for staff S1. The document states that S1 cannot be present in or work with any residents of a facility licensed by the Department of Social Services.

The Exclusion was delivered to facility Executive Director Morgan Whinery.

While LPAs were at the facility staff S1 came in to work the daily shift. The staff was brought into the Executive Director's office and the Exclusion was delivered and read to S1. S1 was informed S! can no longer be present in or work with residents of a facility licensed by the Department. LPA asked S1 if there were any questions. LPAs then witnessed that S1 then left the facility.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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