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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:57:18 PM


Document Has Been Signed on 08/29/2024 03:57 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: 77DATE:
08/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Antoinette Edwards, Executive DirectorTIME COMPLETED:
03:19 PM
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On August 29, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Case Management visit LPA met with Antoinette Edwards and informed her the reason for the visit

This Case Management visit is regarding the Stipulation and Order. The ED informed LPA the facility currently has 8 residents with Covid-19. LPA informed ED that this Case Management visit will continue via teleconference. LPA left the facility to continue from home.
Copy of the Stipulation and Waiver and Order was delivered and served to the facility 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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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