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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 09/27/2022
Date Signed: 09/27/2022 01:00:49 PM


Document Has Been Signed on 09/27/2022 01:00 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:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 59DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Kayla Davis, Executive DirectorTIME COMPLETED:
12:45 PM
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On, September 27, 2022, at 10:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with , Executive Director, Kayla Davis and explained purpose of the visit. Prior to initiating the inspection LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE). Additionally, LPA was screened by the front desk personnel upon arrival.

Kayla and LPA completed the inspection tool questionnaire with no issues or advisories to report. Currently, the facility does not have Covid-19. No issues for concerns at this time.

LPA observed the following:
Administrator certificate is valid 1/16/2024. First aid kit fully stocked and ready for emergency use. Common areas were clean and in good repair. Smoke and carbon monoxide detectors are operational. Fire extinguishers fully charged and the Facility temperature measured 74 degrees F. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medications are properly stored and locked away.

To continue see 809 -C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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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: VILLAGE AT HERITAGE PARK, THE
FACILITY NUMBER: 342700202
VISIT DATE: 09/27/2022
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As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

Executive Director shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office.

Administrator shall submit the listed documents to Licensing later than October 27, 2022.

An exit interview was conducted and a copy of this report was given to Kayla.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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