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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005513
Report Date: 01/07/2021
Date Signed: 01/07/2021 12:28:46 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: 73DATE:
01/07/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sharon Monck- District Director of Operations
Ed Silva- Interim Executive Director
TIME COMPLETED:
10:30 AM
NARRATIVE
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A Non-Compliance Conference was conducted today in the Sacramento North Regional Office. The purpose of this Non-Compliance Conference meeting is to discuss complaints/inability to remain in substantial compliance with the regulations/or specific incident that has occurred in the last 12 months. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, LPM Laura Munoz, Licensing Program Analyst (LPA) Sarena Keosavang, Brookdale Sterling Court District Director of Operations Sharon Monck, Interim Executive Director Ed Silva, Clinical Service Registered Nurse Alicia Scott, Vice Present of Operations Deirdre Brown, Counsel Joel Goldman, and Nurse Jina Amstutz. The Non-Compliance Conference process was explained during this meeting.

The facility was cited for 3 Type A citations and 2 Type B citations. The facility was cited the following citations: Basic Services, Incidental Medical and Dental Care, Enumerated rights and Administrator - Qualifications and Duties. In addition, the facility was assessed civil penalty in the amount of $500.

Issues discussed during the meeting were:
· The amount of substantiated complaint within the last 12 months.
· History of citations.
· Incident that occurred at the facility on 01/04/2020
· Plan of Corrections

The facility shall provide the following to the Department by January 21, 2021:
· LIC 500
· Brookdale Universal fall precaution plan.
· Brookdale policy track and trend of falls.
· Staff training plan on identifying residents who are at fall risk, staff identify change in condition, staff charting, and reporting requirement regarding staff change in condition.
· The facility’s policy on first aid and calling 911.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
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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