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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 11/16/2020
Date Signed: 11/16/2020 03:12:06 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 CITRUS HEIGHTSFACILITY NUMBER:
347003712
ADMINISTRATOR:SCARBERRY, JENNIFERFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 27DATE:
11/16/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jennifer Scarberry, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Bethany Huusfeldt conducted a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. LPA met with Administrator, Jennifer Scarberry and explained the purpose of today's visit. Staff member 1(S1) is excluded as a result not related to this facility.

LPA Huusfeldt handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Jennifer Scarberry and explained that S1 is not allowed back at the facility.

A copy of this report was provided to Administrator
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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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