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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:31:06 PM


Document Has Been Signed on 03/20/2024 03:31 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 35DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Executive Director, Jerilyn PurolTIME COMPLETED:
03:35 PM
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On 03/20/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director (ED), Jerilyn Purol, and explained the purpose of the visit.

LPA and ED conducted a tour of the interior and exterior of the facility. Areas toured include but are not limited to: common areas, ten (10) resident rooms, three (3) common shower rooms, dining rooms, kitchen, outdoor area, lobby, and common restroom. The facility has 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. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured in a residents bathroom at 110 degrees Fahrenheit. First aid kit was completed. LPA observed centrally stored medications area were locked and inaccessible to residents in care. During LPA visit the facility was conducting an elopement drill with staff.

LPA reviewed eight (8) personnel files and eight (8) residents' files. Staff have annual training as well as first aid and CPR. Residents files contain signed admission agreements, updated physician reports, Identification sheets, releases, appraisals needs and service plan, and resident rights.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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