<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700851
Report Date: 10/01/2021
Date Signed: 10/01/2021 11:18:47 AM

Document Has Been Signed on 10/01/2021 11:18 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ASTORIA GARDENSFACILITY NUMBER:
342700851
ADMINISTRATOR:QUILDILIG, KARENFACILITY TYPE:
740
ADDRESS:8609 BANFF VISTA DRIVETELEPHONE:
(916) 714-8685
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
10/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Ann VergaraTIME COMPLETED:
11:10 AM
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
On 10/01/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced case management visit to follow up on a previous facility staff member who can no longer be on facility grounds. At approximately 10:55 AM, LPA met with staff member, Ann Vergara, at the entrance of the facility and explained the purpose of the visit. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

LPA Filouane toured with the facility with the staff member. LPA verified that the previous staff member in question has not been on facility grounds since 09/23/21 and was not working on 10/1/21. LPA toured the facility staff room in the and the facility's backyard. LPA did not observe the previous facility staff member on facility grounds.

No deficiencies were cited today.

Exit interview was conducted with staff member Ann Vergara and a copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1