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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700890
Report Date: 11/14/2023
Date Signed: 11/14/2023 04:44:01 PM


Document Has Been Signed on 11/14/2023 04:44 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: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:
11/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Russelle Robinson, Administrator Designee TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Russelle Robinson, Administrator Designee. Also present were staff, Aizza Gonzales and Nonadel Soriana. LPA observed (2) residents to be resting in recliner chairs in the common area and (4) residents to be resting or watching television in their resident rooms. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently there is (1) resident on hospice.

LPA and the Administrator Designee toured the interior and exterior of the facility including the common areas, (6) resident bedrooms/private half bathrooms, (2) separate full bathrooms, kitchen, staff room, locked medication room, locked laundry and additional storage area. The upstairs area is not used by residents and is gated off. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable/7+day non-perishable supply of food, locked sharps and toxins in the kitchen and medications to be secured nearby. Hot water temperature measured 110*F in the kitchen. There is a separate kitchen sink that dispenses hot water of 125+*- LPA observed the required signage posted. LPA observed sufficient linens/blankets/incontinent supplies, PPE, and a complete First Aid kit. The inside temperature was 76*F. Fire extinguisher last serviced 6/5/2023. Quarterly fire drills are conducted -last drill Nov 2023. There are cameras in the common area with a sign posted as well as other required postings. There is a covered patio with seating and (1+) unlocked gates on the patio. There is signage posted near the Emergency Gas Shut off. All exit doors have alarms. Residents participate in outings.
LPA reviewed (3) resident files and found them to be complete and contain current paperwork. Medications were reviewed for (2) residents and no discrepancies were noted. Medication documentation is current and accurate. (2) staff files were reviewed. LPA observed complete paperwork and staff to have recently completed training hours in excess of what is required annually and have current First Aid/CPR. Infection Control Plan was approved. There are no deficiencies issued during today's inspection. Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023
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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