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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005676
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:30:51 PM


Document Has Been Signed on 06/20/2023 04:30 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:
317005676
ADMINISTRATOR:GAODE, ANNAFACILITY TYPE:
740
ADDRESS:3908 RUTLAN WAYTELEPHONE:
(916) 772-1972
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Anna Gaode TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Lavinia Muscan and Talwinder Bains, LPM Laura Munoz and Regional Manager, Alycia Berryman arrived at the facility and met with Administrator, Anna Gaode. Facility currently have 4 residents in care.

LPA Bains arrived at facility around 1:15pm. Upon arrival at the facility, S1 stated that the licensee left and stated they were not coming back. The licensee stated this was a misunderstanding. S1 stated they were not aware who was in charge of the facility for now as the licensee provided a statement that another individual is in charge. Based on CCL system, there is a pending application for this address that is currently in the licensure process with the Central Applications Bureau. LPM Munoz spoke to the applicant who stated the property was in escrow and there was no agreement that the applicant would take control of property prior to licensure. During LPA Bains inspection, it was found that the facility's phone service and Wifi were not working. S1 indicated she did not have a way to make calls. LPA Bains confirmed that phone was not working at the time of the visit. LPM Munoz attempted to contact the licensee who stated she would be coming to the facility. RM Berryman, LPM Munoz and LPA Muscan arrived at the facility at 2:45pm and was greeted by the licensee and spouse. The licensee stated somehow the Wifi was disconnected which resulted in the phone not working. During the visit, the licensee was able to reconnect the phone.

RM and LPM conducted a walk through of the facility and observed that chemicals and toxins were unlocked and accessible to residents in care in the laundry room, the garage and under kitchen sink. Additionally, during inspection, it has been observed that the facility has insufficient 2 days perishable and 7 days nonperishable food supplies for residents.

Due to interviews conducted and observations made 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 Licensee and a copy of this report and appeal rights were provided to the facility. The signature of the Licensee 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: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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 06/20/2023 04:30 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GARDEN VILLA
FACILITY NUMBER: 317005676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87405(a)

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87405(a)- All facilities shall have a qualified and currently certified administrator. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section...this requirement is not met as evidence by:
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Licensee/administartor will appoint Admin designee(s).. The licensee shall submit an LIC309 of appointed designee as well as submit an LIC500 to department by POC date 06/21/23.
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Based on LPA visit on 06/20/23 and S1s statement, facility does not has designated administrator during today's visit as required per above regulation, which poses a immediate health and safety risks to residents in care.
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Type A
06/21/2023
Section Cited
CCR87555(b)(26)

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87555(b)(26)- General Food Service Requirements- Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not as evidence by;
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Licensee/administartor will send statement of understanding for regulation 87555(b)(26) and to enusre that facility has supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises and send POC to department by 06/21/23.
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Based on observation, facility did not have supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days as required per above regulation which poses a immediate health and safety concerns for residents in care.
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Additionally, facility will submit proof of food receipts till 7/20/23 to CCLD on weekly basis for food purchases.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/20/2023 04:30 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GARDEN VILLA
FACILITY NUMBER: 317005676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87705(f)(2)

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Care of Persons with Dementia 87705 (f)The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by ...
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Licensee/Administrator will make sure that all chemicals and toxins are locked and inaccessible to residents in care and will send statement of understanding of this regulation to CCLD by POC due date 6/21/23.
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Based on facility observation on 6/20/23, it has been observed that facility staff leaving chemicals and toxins unlocked and accessible to residents in care including areas such as laundry room, garage and under kitchen sink which poses an immediate health and safety risk to ressidents in care.
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Type A
06/21/2023
Section Cited
CCR87468.1(a)(14)

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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:(14) To have reasonable access to telephones, to both make and receive confidential calls... This requirement is not met as evidenced by ...
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Licensee/Administrator will make sure that facility has working phone service at all times as required by this regulation and will send statement of understanding of this regulation to CCLD by POC due date 6/21/23.
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Based on facilty obsevation on 6/20/23 and S1s statement, facility does not have any working phone number as required by this regulation which poses an immediate health and safety risk to ressidents 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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3