<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005468
Report Date: 05/18/2021
Date Signed: 05/18/2021 06:06:51 PM

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:CHRISTINE SALEEFACILITY TYPE:
740
ADDRESS:11550 EDUCATION STTELEPHONE:
(530) 888-8847
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:110CENSUS: 70DATE:
05/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Kylie Whitaker (Health and Wellness Director)TIME COMPLETED:
06:15 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
Licensing Program Analyst (LPA) Konnor Leitzell conducted an unannounced virtual case management visit with Health and Wellness Director (HWD) Kylie Whitaker. Case management was conducted via tele-phone to discuss an incident report submitted to Community Care Licensing (CCL) on 5/17/2021. Incident report is regarding Resident sustaining a fracture from an un-witnessed fall on 5/14/2021. An interview was conducted with HWD to better understand the time frame of the incident.

Through the interview conducted with HWD Kylie Whitaker, LPA discovered facility staff conducts their schedule checks, referred to as “rounds”, between the hours of 2a.m. and 3a.m.; and again between 5a.m.-6a.m. LPA was informed rounds were conducted as normal, and during second round conducted caregiver heard Resident call out for help (roughly 5:30a.m.). Upon entering Resident’s room, caregiver witnessed resident on the floor in their restroom. Through reviewing the Incident Report submitted LPA discovered facility immediately dialed 911; contacted Resident’s responsible party; and primary physician.

No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report is being provided via email to Health and Wellness Director Kylie Whitaker. HWD is to sign and return one copy of report via email to LPA Leitzell, and keep one copy on file.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1