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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002796
Report Date: 06/12/2023
Date Signed: 06/12/2023 11:47:36 AM


Document Has Been Signed on 06/12/2023 11:47 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:SWAN LAKE VILLAFACILITY NUMBER:
315002796
ADMINISTRATOR:MAKANONENG, ANDREWFACILITY TYPE:
740
ADDRESS:9702 SWAN LAKE DRTELEPHONE:
(916) 797-8521
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:7CENSUS: 6DATE:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aurora PetraTIME COMPLETED:
12:00 PM
NARRATIVE
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LPA Parks arrived on Monday June 16, 2023 to complete the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (6) and staff files (4). All resident files contained the required paperwork. Three out of four of the staff files reviewed did not contain TB test/results.

LPA Parks and staff Aurora toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. Water temperatures in kitchen and bathrooms were within the required range of temperatures.

LPA observed the garage was converted into two staff bedrooms. Based on the Fire Safety Inspection (STD 850) conducted on 6/7/2021 and facility sketch, the garage does not have fire clearance approval to be used as bedrooms. Please see 9099-D for citation issued. Due to technical issues, LPA was unable to cite for an immediate civil penalty of $500. This will be issued at a later date.


Exit interview conducted. Appeal rights were printed and given to the facility. A copy of this report was emailed to Facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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 3


Document Has Been Signed on 06/12/2023 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: SWAN LAKE VILLA
FACILITY NUMBER: 315002796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203


This requirement is not met as evidenced by: facility garage being used as two staff bedrooms.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2023
Plan of Correction
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Aurora and Licensee Andrew to find alternative living place for two staff. Facility to submit document stating that staff are no longer living in the garage by end of day 6/13/2023. Possibly to convert garage into approved staff living spaces in the future.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/12/2023 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: SWAN LAKE VILLA
FACILITY NUMBER: 315002796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411


This requirement is not met as evidenced by: three staff files not containing TB records.
Deficient Practice Statement
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4
Based record review, the licensee did not comply with the section cited above in 3 out of 4 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
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Facility to provide proof of staff TB tests/results by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3