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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 04/15/2021
Date Signed: 04/15/2021 11:46:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:BROOKDALE FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:ED SILVAFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 78DATE:
04/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kristine Clawson (Admin)TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Konnor Leitzell contacted Kristine Clawson to conduct a case management visit regarding a Death Report (LIC 624A) Community Care Licensing (CCL) received on 04/10/2021. LPA conducted case management via telephone due to COVID-19 Precautionary measures. LPA explained the purpose of the visit.

The facility notified CCL on 04/10/2020 that R1 was found unresponsive by staff on 04/04/2019. Facility called 9-1-1 and family once R1 was found to have no vitals; the Paramedics pronounced R1’s cause of death as Cardiac Arrest. Facility notified R1’s MD and RP immediately.

During today's call, LPA requested the following documents for R1: Admission Agreement, Care Plan, Charting Notes and LIC602. LPA has also requested Staff Roster and schedule for 4/4-4/10. LPA is requesting documents to be submitted to CCL by COB 4/16/2021.

No deficiencies are being cited as a result of today's case management.
Exit interview conducted and copy of report to be sent to admin via email.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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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