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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005467
Report Date: 07/18/2024
Date Signed: 07/18/2024 11:33:46 AM


Document Has Been Signed on 07/18/2024 11:33 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: 88DATE:
07/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shari KranigTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 18, 2024 to follow up on an incident that was received by the Department on 7/14/2024.

LPA learned that R1 has a routine of wandering throughout memory care and the memory care courtyard. LPA obtained R1's physicians report, current care plan, and hospital discharge paperwork. They are diagnosed with Dementia. On July 4, 2024, R1 was found in the courtyard, sweating and having labored breathing.

LPA interviewed caregivers and med tech who were on duty on the date of the incident. Per staff, R1 is checked on hourly. Staff could not remember the specific time that they last saw R1 however, R1 was observed walking in the courtyard prior to lunch, which is a part of their daily routine. As the food was being served, staff were notified that R1 was in distress. Staff then followed protocol for a medical emergency.

Since the incident, the facility has since began to utilize the alarms on the interior courtyard doors to alert staff when a resident goes out to the courtyard. These alarms are to be on when there is excessive heat.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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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