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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 01/29/2024
Date Signed: 01/29/2024 11:40:37 AM


Document Has Been Signed on 01/29/2024 11:40 AM - 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 FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 91DATE:
01/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sharisse Toves, Health and Wellness DirectorTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 1/29/24, and met with the Health and Wellness Director, Sharisse Toves, to follow-up on a case management visit regarding an SOC341 that was received by the Department on 1/9/24.

On 12/13/23, resident (R1) reported to facility staff (S1) that staff (S2) was rough with them. S1 immediately informed the Executive Director, Kristine Clawson. On 12/13/23, The facility placed S2 on suspension pending internal investigation. S2 did not have further access to R1. Folsom Police Department (PD) was notified of the incident and created an incident report #2312140053. No formal case was opened with Folsom PD as they did not suspect abuse. At the conclusion of the facility's internal investigation, they did not find S2 abused R1. On 12/14/23, the facility terminated S2, due to other ongoing performance issues.

The Health and Wellness Director indicated that the facility has been having issues with their fax machine and had to resend the SOC341 on 1/9/24. The original sent date was 12/14/23.

No deficiencies were cited.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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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