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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:11:11 PM


Document Has Been Signed on 04/25/2024 03:11 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 FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 86DATE:
04/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Sharisse Toves, Health & Wellness DirectorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/25/24, and met with the Health and Wellness Director, Sharisse Toves, to conduct a case management visit regarding an incident report received by the Department on 4/15/24.

On 4/11/24, resident (R1) was found at a coffee shop down the street from the facility. The coffee shop employee called the police. The police arrived at the coffee shop and used R1's phone to call their responsible party. The police returned R1 back to the facility. No injuries were reported.

R1 resides in the assisted living section of the facility and is currently receiving hospice care. On 4/15/24, the Department received R1's Physician's Report LIC602A, dated 7/5/22, which indicated that R1 is unable to leave the facility unassisted.

On 4/24/24, the facility conducted an in-service training with all staff regarding missing residents/elopement.

As a result of today's visit, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87464(f)(1) regarding care and supervision of residents. The deficiency is listed on the LIC809-D.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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Document Has Been Signed on 04/25/2024 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BROOKDALE FOLSOM
FACILITY NUMBER: 347005467

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
87464(f)(1)

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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Facility conducted an in-service training following the AWOL with all staff regarding missing residents/elopement. Facility provided a copy of the in-service training to LPA by the POC due date of 4/26/24.
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Based on records reviewed and interviews conducted, the facility did not ensure that residents R1 was properly supervised, resulting in AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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