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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700694
Report Date: 08/25/2021
Date Signed: 08/25/2021 05:09:22 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:BROOKHAVEN HOME CAREFACILITY NUMBER:
342700694
ADMINISTRATOR:ARTAN, ADELA CLAUDIAFACILITY TYPE:
740
ADDRESS:5916 SHADOW OAK DRIVETELEPHONE:
(916) 903-7688
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Adela "Claudia" Artan, administratorTIME COMPLETED:
02:30 PM
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**Due to technical difficulties Licensing Program Analyst (LPA) generated report after visit, a handwritten copy with signatures was provided to administrator Adela "Claudia" Artan at time of inspection. Electronic copy of this report will be sent to administrator and LPA requests a signed copy is returned to Community Care Licensing (CCL) for facility records.**

LPA arrived at the facility unannounced on 08/25/2021 to conduct a collateral visit, LPA met with administrator and explained the purpose of today's visit. Prior to conducting visit LPA completed required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask; administrator screened LPA upon entry.

LPA conducted interviews with administrator and resident (R1) regarding a complaint filed against another facility, LPA requested administrator send LPA the following documents by 08/27/2021 to assist with complaint investigation:
  • Proof of control of property;deed
  • Copy of facility's liability insurance.
  • R1's 602 and admission agreement.


No deficiencies are cited as a result of today's inspection. Exit interview was conducted and a copy of this report was emailed to administrator. LPA requests a signed copy is returned to CCL by either fax or email.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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