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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 10/20/2023
Date Signed: 10/20/2023 04:36:39 PM


Document Has Been Signed on 10/20/2023 04:36 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:ATRIA EL CAMINO GARDENSFACILITY NUMBER:
347000389
ADMINISTRATOR:KIMBERLY HAGENFACILITY TYPE:
740
ADDRESS:2426 GARFIELD AVETELEPHONE:
(916) 488-5722
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:325CENSUS: 192DATE:
10/20/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kim HagenTIME COMPLETED:
01:25 PM
NARRATIVE
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On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived at the facility unannounced to conduct a required quarterly case management visit in accordance with the Stipulation and Order, effective date 06/01/2022 to 05/31/2024. LPAs met with the Executive Director (ED), Kimberly Hagen, and explained the purpose of the visit.

During today's visit, LPAs observed the Stipulation and Waiver and Order to be posted in a conspicuous space in facility hallway. LPAs observed the facility to be clean, safe, sanitary and in good repair. LPAs reviewed facility's Stipulation binder and reviewed the orders of the stipulation. LPAs observed the facility to conduct daily audits of emergency call response. LPAs observed documentation of facility's monthly staff training. LPAs observed records of resident care task audit, staff numbers and observed sufficient staff per resident care needs. Additionally, LPAs observed incident reports submitted to LPA Yang for emergency call responses which exceeds 10 minutes.

As a result of today's visit, LPAs observed the facility to be in compliance to Stipulation and Waiver and Order.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
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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