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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002339
Report Date: 08/23/2021
Date Signed: 08/23/2021 11:53:12 AM

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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kenny Singh- StaffTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 08/23/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff, Kenny Singh and explained the purpose of the visit. Licensee is unable to meet LPA at the facility. Licensee stated staff will be at the facility to assist LPA. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with Kenny Singh to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
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)
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