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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:35:19 PM


Document Has Been Signed on 04/05/2023 02:35 PM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:BROOKDALE SYLVAN RANCHFACILITY NUMBER:
347003712
ADMINISTRATOR:JERILYN PUROLFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:56CENSUS: 30DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Executive Director: Jerilyn Purol TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Sarena Keosavang and Sarah Benson arrived at the facility unannounced on 04/05/2023 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPAs met with Executive Director, Jerilyn Purol, and explained the purpose of the visit.

At 9:10 AM, LPAs toured the facility with ED to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, nine (9) residents apartments, two (2) common shower rooms, dining room, kitchen, outdoor area, lobby, and common restroom. The facility is built in four wings or "houses", with each house having a separate dining area. Food is cooked in a central kitchen and brought out to each house. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed fire detectors and carbon monoxide present in all residents' bedrooms. Bathrooms are clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 108 degrees Fahrenheit. First aid kit was completed. LPA observed centrally stored medications area were locked and inaccessible to residents in care. Licensing complaint poster are posted as required.

At 10:10 AM, LPAs reviewed three (3) staff files and five (5) residents' files. Staff have training in dementia, first aid and CPR, and other various areas of care provision. Med Techs have received required training in medications. Residents files contain signed admission agreements, updated physician reports, Identification sheets, releases, preplacement appraisals, and client rights. At 1:15 PM, medications were reviewed for 5 residents. Medications are centrally stored, locked, and appear to be given per doctor order. Facility keeps electronic MARS on a computer.

LPA requested for ED to submit documents for review.
  • Updated LIC 500
  • Administrator's Certificate
  • Updated LLC-12
  • Control of Property (Copy of Lease or Grant Deed)

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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