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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 05/02/2024
Date Signed: 05/02/2024 01:18:34 PM


Document Has Been Signed on 05/02/2024 01:18 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: 33DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Executive Director, Jerilyn PurolTIME COMPLETED:
01:20 PM
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On 05/02/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Case Management Incident visit. LPA met with Executive Director (ED), Jerilyn Purol, and explained the purpose of the visit.

The purpose of the visit is to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 04/25/2024. The report indicates that Staff #1 (S1) allegedly used force to redirect a resident from another resident’s room.

During today’s visit LPA and ED discussed the incident that occurred. Facility conducted an internal investigation as well. Since the time the incident occurred R1 has moved out of the facility to receive a higher level of care. Additionally, LPA requested a copy of R1s file and staff training.

At this time, deficiencies are not being cited.



Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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