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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:28:10 PM


Document Has Been Signed on 10/20/2023 02:28 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:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:KENT MULKEYFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 91DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anntonette Edwards, ExecutiveTIME COMPLETED:
02:15 PM
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On October 20, 2023, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Required 1- Year Inspection. LPA met with Anntonette Edwards, Executive Director (ED) and explained purpose of the inspection.

LPA and Anntonette conducted the Infections Control Questionnaire with no issues or concerns.

The facility is an 2 story hotel style building that is licensed to serve (108 ) seniors. Currently, the facility has 102 rooms, a dining room, activity room, a gym, hair salon and a multi-purpose room.
LPA and the ED toured the grounds, including the dinning room multi-purpose room, offices, and visitation area. LPA observed it to be clean, safe and in good repair. LPA observed required postings, Covid posters and Emergency Disaster Plan, Resident Rights to be posted in appropriate areas. LPA observed PPE, including sanitizer to be present at the entrance of the building. There are multiple First Aid kits on site.

LPA observed all fire extinguishers and smoke alarms were serviced and ready. LPA interviewed (5) client and reviewed (5) client files. LPA interviewed (5) staff and reviewed (5) staff files. All files reviewed were found to contain current documentation, including staff training. Most residents have their meals in the dinning room. Staffing ratios were observed to be 3:1, as required and all staff have current First Aid/CPR certifications. ED advised LPA that the facility has a change of ownership pending. The application has been submitted to the Department. December 1, 2023, is the estimated time this will take effect. LPA did not request updated copy of LIC308 and LIC500 due to the upcoming change. There were no deficiencies observed. Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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