<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002339
Report Date: 08/23/2021
Date Signed: 08/23/2021 12:13:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GARDEN VILLAFACILITY NUMBER:
315002339
ADMINISTRATOR:KAUR, KANWALPREETFACILITY TYPE:
740
ADDRESS:1104 NOTTINGHAM COURTTELEPHONE:
(916) 871-4682
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
08/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kenny Singh, Administrator's Husband. TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/23/2021 at 11:00 AM, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility via continue complaint investigation. LPA discussed the purpose of the visit with Administrator's husband, Kenny Singh as the Administrator was busy and could not come to facility..

LPA interviewed three residents (R 1-3), three other residents were asleep so LPA did not interview them. LPA also interviewed two staff (S 1-2). LPA is still attempting to reach two other individuals via phone who were visiting and may have witnessed the incident.

Due to insufficient information available at this time, the above allegations needs further investigation. LPA informed Administrator that the complaint will need further investigation and shall take approximately one week to complete the investigation.

An exit interview was conducted with Kenny Singh, Administrator's husband, and a copy of this report will be provided to the facility via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1