342700202-2-9-2023-25-AS-AHOD-CNVV6M-20230209150947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:10:40 PM

Document Has Been Signed on 02/09/2023 03:10 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, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	KENT MULKEY		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS: 60	DATE:	02/09/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rickay Hidalgo, Vice President of Operations		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An office meeting was conducted today via Microsoft Teams with Vice President of Operations, Rickay Hidalgo, to discuss the Stipulation and Waiver and Order, which was signed and ordered on 01/25/2023. Present at the meeting were Licensing Program Analyst, Angela Hood, Licensing Program Manager, Laura Munoz, and Regional Manager, Alycia Berryman. Copy of the Stipulation and Waiver and Order was delivered and served to the facility. The Stipulation and Waiver and Order was discussed to all present in the meeting. Facility acknowledges said document and agrees to abide by the contents set forth in said Stipulation and Waiver and Order. Per the Stipulation and Order the facility is on a 3-year probation effective 01/25/2023. Per the terms and agreement of the Stipulation, the facility shall operate the facility in strict compliance with the regulations and statutes governing the operation of a residential care facility for the elderly. During the period of probation, the Department in its sole discretion may conduct unannounced site visits. The licensee shall ensure that the Department has access, within no more than one hour, to all personnel and client records, including any and all records of residents and their care. The Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. Licensee shall abide by all terms and conditions set forth in the above referenced Stipulation and Waiver and Order. *****************************************Continued on LIC809-C******************************************

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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: 02/09/2023

NARRATIVE

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Licensee has agreed to provide CCL with the following information as requested in today's meeting:

The licensee shall submit to the licensing office a written summary of their hiring and training practices, including job descriptions for each position at the facility.
The licensee shall, within sixty (60) days of execution of the Stipulation (03/05/2023), obtain a consultant to come to the facility on a yearly basis for a period of three years to evaluate the facility's compliance with the regulations and assessing. Facility must submit consultant's evaluation to their Licensing Program Analyst on an annual basis. The consultant needs to be reviewed and approved by the Regional Manager.
The licensee shall submit a medication audit schedule which is required to be performed quarterly and audits of medication records shall be performed monthly.
The licensee shall submit a schedule when weekly checks of all emergency exits are to be conducted.
The licensee shall submit a plan on how the facility will ensure that all egress devices and auditory alarms are in working order and operating properly.
The licensee shall, within sixty (60) days of execution of the Stipulation (03/05/2023), develop and maintain a plan to address client needs and protect other clients in the above scenarios, including additional 1-on-1 resident supervision and/or relocation/eviction in cases where aggressive or threatening behavior is observed. Plan must be submitted to the licensing office for approval.
The licensee shall submit a staffing schedule to the licensing office that meets the agreed ratios: There shall be a minimum of three (3) qualified direct care employees in the memory care unit during the morning and evening shifts, not including the person responsible for dispensing medication. There shall be a minimum of two (2) direct care employees in the memory care unit during the overnight shift, not including the person responsible for dispensing medication.
The licensee shall submit to the licensing office a written protocol for admissions specifically describing the communication procedures for staff on shift to be informed of new admissions.
The licensee shall submit to the licensing office a written protocol for communication between staff persons during shift changes to ensure that incoming staff are aware of the condition of each client and any incidents of occurrences that occurred during the prior shifts.

No violations were cited during today's meeting. Exit interview conducted. Copy of report provide via email for signature.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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