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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 02:24:03 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:
02:00 PM
MET WITH:Carol DowellTIME COMPLETED:
02:30 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 06/21/2020. 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. R1 was unable to standup and appeared to be in pain on R1's left shoulder. R1 was on hospice. R1 was sent to the hospital for evaluation.

LPA interviewed Carol regarding the report. The interview with Carol indicates that R1 returned to the community the same day he was sent to the hospital with a clavicle fracture. LPA requested for R1's physician report, death report, and discharge medical document.

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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