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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005513
Report Date: 06/10/2020
Date Signed: 06/10/2020 01:55:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BROOKDALE STERLING COURTFACILITY NUMBER:
317005513
ADMINISTRATOR:DOWELL, CAROLFACILITY TYPE:
740
ADDRESS:100 STERLING CTTELEPHONE:
(916) 786-7200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:128CENSUS: 71DATE:
06/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Carol DowellTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to conduct a Case Management visit via telephone (regarding the incident occurrence of 06/01/2020) due to COVID-19 and pre-cautionary measures. LPA stated the purpose of the call.

LPA Keosavang requested a copy of resident’s plan of care, physician’s report, and discharge medical records.

An exit interview was conducted with Carol Dowell, Administrator, via telephone. A copy of this report will be provided to the facility via Email. The report is to be signed and returned to LPA via Email.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
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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