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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002339
Report Date: 09/17/2026
Date Signed: 09/17/2026 04:01:38 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/17/2026 04:01 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:GARDEN VILLAFACILITY NUMBER:
315002339
ADMINISTRATOR/
DIRECTOR:		KAUR, KANWALPREETFACILITY TYPE:
740
ADDRESS:1104 NOTTINGHAM COURTTELEPHONE:
(916) 787-1951
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 6DATE:
09/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator - Preety KaurTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 09/17/2026, Licensing Program Analyst (LPA) Graham Gunby arrived to the facility unannounced to conduct a Required 1- year annual inspection. LPA was unable to open the CARE tool during this visit. LPA met with the Administrator, Preety Kaur, and explained the purpose of today's visit.

The facility is licensed for six (6) non-ambulatory residents, hospice waiver of two (2). LPA was informed there are two (2) residents receiving hospice services.

During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathroom, kitchen, backyard and the common areas. LPA observed medication and sharps to be locked and secured. LPA observed cleaning solutions and disinfectants unlocked and accessible to residents in care. LPA observed fire extinguishers to be last serviced on 02/10/2026. Water temperature was measured in the kitchen sink at 117.3 degrees Fahrenheit.

LPA reviewed six (6) residents files and three (3) staff files. Three (3) of six (6) resident records did not contain all required documentation. Staff files did not contain current and up-to-date CPR/First Aid training.

Deficiencies are being cited during today's visit on LIC809-D


Exit interview conducted and a copy of the report will be emailed to Administrator.
Troy Ordonez
Graham Gunby
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/17/2026 04:01 PM - It Cannot Be Edited


Created By: Graham Gunby On 09/17/2026 at 03:15 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GARDEN VILLA
FACILITY NUMBER: 315002339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2026
Section Cited
CCR
87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Facility will ensure that all hazardous items are locked and inaccessible to the residents in care at all times. Administrator will complete a statement of understanding regarding regulation 87309 and submit to LPA by POC due date of 09/18/2026.
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Based on LPA's observation, facility did not ensure that cleaning products and disinfectants were inaccessible to residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type B
10/17/2026
Section Cited
CCR87623(b)(2)

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87623(b)(2) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by:
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The Administrator shall develop policies and procedures for the care of residents with indwelling catheters which complies with the requirements of 87623. Administrator shall coordinate a skilled professional to train facility staff for this procedure. The policy shall be emailed to LPA by 10/17/2026.
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Based on LPA's review of records and statements by the Administrator, the Licensee failed to ensure catheter bag for R5 was changed by an appropriately skilled professional.
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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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Graham Gunby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/17/2026 04:01 PM - It Cannot Be Edited


Created By: Graham Gunby On 09/17/2026 at 03:19 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GARDEN VILLA
FACILITY NUMBER: 315002339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2026
Section Cited
CCR
87629(b)(1)

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87629 Injections.
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by:
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Administrator to send into LPA a copy of their plan for diabetic residents going forward. Administrator will coordinate a skilled professional to provide staff with training regarding injections and glucose monitoring. Plan to be emailed to LPA by 10/17/26.
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Based on interviews and record review, the licensee did not comply with the section cited above due to facility not having a diabetic management plan along with R3’s 602 stating they cannot perform their own injections or glucose monitoring which poses an potential health and safety risk to persons in care.
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Type B
10/17/2026
Section Cited
HSC1569.618(c)(3)

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Administration/Management- Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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Administrator agreed to immediately schedule staff to attend CPR training. Administrator also agrees to have one staff person on site at all times with a CPR card. Administrator will send to CCL a copy of staff CPR cards by 10/17/2026.
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LPA did not observe any CPR cards in files for S1 during visit. Administrator acknowledged that one staff had a CPR card but it was not at the facility. It was stated working staff have CPR training, but could not provide confirmation.
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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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Graham Gunby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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