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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 07/07/2020
Date Signed: 07/07/2020 12:59:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:MELISA TIBURCIOFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 36DATE:
07/07/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Melisa TiburcioTIME COMPLETED:
01:05 PM
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On July 7, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Executive Director (ED), Melissa Tiburcio, via telephone to obtain additional information regarding an incident that occurred at the facility and was reported to the Department on 7/6/2020. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on a SOC 341 Report and Suspected Dependent Adult/Elderly Abuse that was submitted to Community Care Licensing (CCL). This report indicates that a resident (R1) had confided with a staff (S1) at the facility about couple of checks issued to another staff (S2) member. S1 had notified Executive Director of the financial abuse. The facility had gathered evidence of the cashed checks. The facility has reported the incident to law enforcement, ombudsman, and R1’s responsible party.

LPA interviewed the ED regarding the report. LPA requested for ED to send CCL pertinent documents such as R1’s 602, R1’s responsible party information, R1’s bank/account information, copies of statements, copies of cashed checks, S2’s information, S2’s employment application, and any other documents regarding the incident.

At this time, deficiencies are not being cited.

An exit interview was conducted. A copy of this report has been emailed to the facility and the Executive Director, Melissa Tiburcio, was advised that a signed copy of the report shall be emailed to LPA.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2020
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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