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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002819
Report Date: 01/18/2024
Date Signed: 01/18/2024 11:41:08 AM

Document Has Been Signed on 01/18/2024 11:41 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:BRIDGEWAY SENIOR CARE, LLCFACILITY NUMBER:
315002819
ADMINISTRATOR:JACKSON, SAYEHFACILITY TYPE:
740
ADDRESS:313 WORDSWORTH COURTTELEPHONE:
(916) 893-3099
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
01/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sayeh Jackson, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue annual inspection. LPA met with Administrator Sayeh Jackson during today's inspection.

LPA reviewed 2 of 5 resident files and 2 staff files. LPA reviewed medications of two residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance.

Deficiencies cited on 809-D.

Exit interview and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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Document Has Been Signed on 01/18/2024 11:41 AM - It Cannot Be Edited


Created By: Bethany Mirlohi On 01/18/2024 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BRIDGEWAY SENIOR CARE, LLC
FACILITY NUMBER: 315002819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
87412 Personnel Records. (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, staff records were unavailable for LPA to review during initial visit on 01/04/24 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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Administrator agrees to complete a plan on how all facility files will be available for review during normal business hours. Plan to be submitted into CCL by 1/25/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
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