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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700694
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:08:32 AM


Document Has Been Signed on 12/14/2023 11:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adela Artan- AdministratorTIME COMPLETED:
11:15 AM
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On 12/14/23 Licensing Program analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required- 1 year annual inspection utilizing the care tool. LPA met with Administrator, Adela Artan and explained the purpose of visit.

LPA and Administrator conducted a tour of the facility. Areas toured included but not limited to the kitchen, dining room, six (6) residents private bedrooms. four (4) bathrooms, garage, common areas and backyard. LPA observed sufficient furniture and lighting throughout the facility. During the tour LPA observed three (3) residents in the living room watching television, and three (3) residents in their private rooms resting.

LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins and knives to be locked and inaccessible to residents in care. LPA also observed centrally stored medications are kept locked and inaccessible to residents. All required posting is present in the facility. Hot water temperature was measured at 116 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. Fire extinguishers was last inspected on 09/19/23. Smoke detectors are working and present throughout the facility. LPA observed four (4) carbon monoxide detectors throughout the facility.

LPA conducted a file review of three (3) resident files and two (2) staff files. LPA observed all resident files and staff files to be in compliance.

LPA requested a copy of the current liability insurance to be sent to LPA Ratajczak by 12/15/23.

LPA completed the full care tool and no deficiencies was observed.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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