317005468-6-13-2025-59-AS-TTRN-DHLTG3-20250613144229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 317005468
Report Date: 06/06/2025
Date Signed: 06/13/2025 02:43:17 PM

Document Has Been Signed on 06/13/2025 02:43 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BROOKDALE AUBURN		FACILITY NUMBER:	317005468
ADMINISTRATOR/ DIRECTOR:	MALISSA ACUNA		FACILITY TYPE:	740
ADDRESS:	11550 EDUCATION ST		TELEPHONE:	(530) 888-8847
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY: 110	TOTAL ENROLLED CHILDREN: 0	CENSUS: 97	DATE:	06/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Malissa Acuna, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On June 6, 2025 LPA Tryon visited the facility to conduct an annual inspection. LPA met with Executive Director Malissa Acuna. The facility currently has 97 residents. LPA toured the facility with ED including common areas, dining rooms, kitchen, hallways, resident rooms, bathrooms, medication room, recreation areas, offices. The facility is clean and in good condition. Rooms/apartments are nicely furnished and decorated. Maintenance appears to be ongoing as needed and facility is kept in good shape. LPA toured 6 resident apartments in Assisted Living, and 3 apartments in memory care. LPA was able to speak with 4 residents. LPA viewed fire extinguishers that were all charged and up to date. Fire system/alarms/carbon monoxide detector system installed, checked regularly. Last inspection was 5/15/2025. System is checked quarterly. Johnson Control is the company who checks the system. LPA toured kitchen and food storage. Kitchen appeared to be clean, well-furnished with pots and pans, utensils, necessary tools and appliances, and a good supply of dishes. Food supplies appear to be varied and of good quality. Supply appears to meet the requirement of 2 days perishable and 7 days non-perishable supplies. LPA reviewed 5 resident files and 3 staff files. Files appear to contain required documents and information. Staff records include training in required areas. Staff records include fingerprint clearance and/or exemptions. Medications are kept organized in locked med carts, inside a locked medication room. Most medications are in bubble packs. Centrally stored medication logs are maintained. Temperature in the building was comfortable. Residents appeared to be active and in good spirits overall. At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit. Exit interview conducted.

Troy Ordonez	TELEPHONE: (916) 263-4832
Todd Tryon	TELEPHONE: (916) 263-4700
	DATE: 06/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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