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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005676
Report Date: 03/25/2022
Date Signed: 03/25/2022 04:09:48 PM


Document Has Been Signed on 03/25/2022 04:09 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GARDEN VILLAFACILITY NUMBER:
317005676
ADMINISTRATOR:GAODE, ANNAFACILITY TYPE:
740
ADDRESS:3908 RUTLAN WAYTELEPHONE:
(916) 772-1972
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Anna Gaode TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains arrived at the facility and met with Administrator, Anna Gaode, to follow-up on an Unusual Incident Report (IR) received by the department on 3/7/2022. Facility currently does not have any COVID-19 positive cases. LPAs wore N-95 masks while in the facility.

IR received on 3/7/2022 stated that resident (R1) was transported to the hospital on 3/1/2022 due to an unwitnessed fall. During hospital stay, social worker contacted Administrator indicating that R1 will need "mass assistance," including the need for a hoyer lift and two or more staff to provide 24/7 care to R1.

Interview with Administrator conducted during today's visit indicated that Administrator told the social worker that the facility would not be able to take back resident due to change in condition. Administrator stated that no eviction notice was issued to R1 prior to not accepting back resident from the hospital.

During today's visit, LPAs observed staff not wearing face coverings while providing care to residents. LPAs were also not screened for COVID-19 related symptoms upon entry of the facility.

Due to interviews conducted and LPAs' observation during today's visit, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page.

Exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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 2


Document Has Been Signed on 03/25/2022 04:09 PM - 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: GARDEN VILLA
FACILITY NUMBER: 317005676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited

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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement is not met as evidence by:
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Based on interviews conducted and records reviewed during inspection on 3/25/2022, facility did not ensure that R1 was issued an eviction notice prior to not accepting back resident to facility, which poses a potential health, safety, and personal rights risk to the residents in care.
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Type B
04/08/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
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During inspection conducted by CCLD on 3/25/2022, LPAs observed staff not wearing face masks while inside the facility and LPAs were not screened for COVID-19 related symptoms upon entry, which poses a potential health, safety, and personal rights risk to the residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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