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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:18:16 PM


Document Has Been Signed on 06/13/2024 03:18 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 FOLSOMFACILITY NUMBER:
347005467
ADMINISTRATOR:KRISTINE CLAWSONFACILITY TYPE:
740
ADDRESS:780 HARRINGTON WAYTELEPHONE:
(916) 983-9300
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:130CENSUS: 89DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maurissa Eidenshink, Business Office ManagerTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 6/13/24 and met with Maurissa Eidenshink, Business Office Manager, to conduct a Required-1 Year Inspection.

During today's visit, LPA reviewed three (3) assisted living resident files and two (2) memory care resident files. LPA also reviewed two (2) staff files.

As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to complete annual inspection.

Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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