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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 03/08/2023
Date Signed: 03/08/2023 02:47:17 PM


Document Has Been Signed on 03/08/2023 02:47 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 FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 94DATE:
03/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Exectuive Director: Kristine Clawson TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 03/08/2022 to conduct a Case Management - Health Checks. LPA met with Executive Director (ED), Kristine Clawson, and Health and Wellness Director (HWD) Sharisse Toves. LPA explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff.

LPA toured the facility together with ED and Health and Wellness Director, to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, nine (9) resident bedrooms, nine (9) bathroom, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted with ED.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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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