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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 11/02/2020
Date Signed: 11/02/2020 03:52:51 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: 68DATE:
11/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Melisa Tiburcio, Executive DirectorTIME COMPLETED:
04:00 PM
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On November 2, 2020, at 2pm, Licensing program Analyst (LPA) DeAnna Williams-Lyons arrived at the facility to conduct a case management inspection regarding a fire that occurred on November 1, 2020 at 3pm. LPA met with Melisa Tiburcio, the Executive Director and informed her the reason for the visit.

The location of the fire was 2121 Rose Arbor Drive which is located at the independent living side of the facility which is not licensed through Community Care Licensing(CCL). When the facility's Dining Services Director, was on duty, he heard the alarm system going off at the cottage. He went to the cottages to see what was going on. When he arrived, he noticed that the sprinkler system was on inside the garage but with no fire. There was “smoldering” and ashes in the garage. He noticed there was cigarette butts on the garage floor. The resident was found lying on the ground unresponsive and stiff. He attempted to perform CPR with no response per the 911 operator. The Fire Department was immediately called, however, they were unsuccessful in trying to revive the resident. The coroner came to the cottage and the resident was pounced dead. The resident lived with his wife who was in Washington D.C at the time. There was no structural damage to the cottage.

No report was given to the facility's executive director because the cottages are not licensed by CCL. Any information obtained will be forwarded to the wife as she is next of kin.

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

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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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