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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700890
Report Date: 12/23/2021
Date Signed: 12/23/2021 04:11:10 PM

Document Has Been Signed on 12/23/2021 04:11 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:SUNGARDEN VILLA IIIFACILITY NUMBER:
342700890
ADMINISTRATOR:SINGH, JASMEETFACILITY TYPE:
740
ADDRESS:8371 BUNCHBERRY CT.TELEPHONE:
(916) 560-8849
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
12/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Arminder TakharTIME COMPLETED:
04:30 PM
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On 12/23/2021 LPA Tryon visited the facility at 3:00 p.m. to do a case management visit in response to an incident report dated 12/22/2021. Prior to the visit LPA had checked in with the home to find out that there are currently no known or suspected cases of COVID-19 in the facility, either residents or staff. LPA met with administrator Arminder Takhar.

Report dated 12/22/2021 related that resident R1 had been found unresponsive at 7:20 a.m. R1 was breathing but did not respond. Staff contacted 911. When paramedics arrived, R1 was checked and was doing better. R1 did not want to go out; and R1'a family did not want R1 sent out to the ER. Paramedics recommended staff give R1 her breakfast a little earlier on this date, and she stayed at home. R1 is doing better today. For details of the episode, see LIC 812 of interview with Mr. Takhar. Resident is able to generally do her medications for her condition, with the assistance of staff.

LPA has requested copies of resident Physician Report, Medication Records, Care Plan, other relevant recores. Records will be forwarded to LPA at CCL.

LPA met with R1. She is doing well today, said she feels much better.

At this time, it appears that the facility is assisting R1 to use her prescribed pertinent medications that she is able to physically do for herself, along with other medications. The staff appear to have reacted immediately during the incident, contacted 911, followed directions, and resident was stabilized. Resident is being seen by the doctor for a related condition in a few days.

No deficiencies were issued at this visit.
Exit interview conducted,.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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