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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005513
Report Date: 07/30/2020
Date Signed: 07/30/2020 02:45:36 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:
07/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Carol Dowell TIME COMPLETED:
03:00 PM
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On July 30, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Administrator, Carol Dowell, via telephone to obtain additional information regarding an incident that occurred at the facility on 07/12/2020. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an Unusual Incident/Injury Report that was submitted to CCLD. This report indicated that resident (R1) was found on the floor of R1's apartment. Upon facility's staff assessment R1 had left sided weakness and slurring of speech. 911 was immediately called and paramedics arrived and took R1 to the ER for evaluation.

LPA interviewed Carol regarding the report. The interview with Carol indicates that R1 had a stroke. R1 is currently at a Skilled Nursing Facility and has not returned to the community. The facility does not have an exact date of when R1 will return to community, but once that is figured out LPA will be notified. LPA requested for R1's physician report, discharge medical document, reassessment, and needs and services plan once R1 returns to the community.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and administrator, Carol Dowell, was advised that a signed copy of the report shall be emailed to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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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