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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002339
Report Date: 09/18/2023
Date Signed: 09/18/2023 04:10:17 PM


Document Has Been Signed on 09/18/2023 04:10 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:KAUR, KANWALPREETFACILITY TYPE:
740
ADDRESS:1104 NOTTINGHAM COURTTELEPHONE:
(916) 871-4682
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:TIME COMPLETED:
05:00 PM
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On 9/18/2023 LPA Tryon arrived at the facility unannounced to do an annual visit. LPA was greeted by staff, who said that the administrator was on her way.
Administrator arrived a short time later. LPA toured the facility with the administrator including common areas, kitchen, living room areas, bedrooms, bathrooms, hallways, laundry, outside areas. The house is in good condition, nicely furnished and clean. Bedrooms are spacious and nicely furnished, have appropriate furniture.
Medications are centrally stored in a locked hall cabinet in original containers. Ongoing medication logs are maintained.
Food supplies were reviewed and appear to be fresh, healthy, stored appropriate and of sufficient quantity to meet the requirement of 2 days perishable and 7 days non-perishable supplies.
Smoke and carbon monoxide detectors installed. Fire extinguishers present and charged, were checked/updated in January 2023.
There is plenty of space inside and outside for various activities.
LPA reviewed 2 staff files and 2 resident files. Documentation appears to be appropriate and up to date.
LPA reviewed the CARE Tool with licensee.
At this time, the facility appears to be in substantial compliance with the regulations.

No deficiencies were cited at this visit. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
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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