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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:27:21 PM


Document Has Been Signed on 11/30/2023 03:27 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: DATE:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Assistant Administrator- Cristina OrtezTIME COMPLETED:
03:30 PM
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On 11/30/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to the facility to conduct a case management visit regarding a voicemail LPA received from Executive Director (ED), Kim Hagen. LPA met with Assistant Executive Director (Asst. ED), Cristina Ortez, and explained the purpose of the visit.

LPA was informed ED was not in the community. Asst. ED contacted ED, who spoke to LPA on speaker phone. LPA was informed ED is relocating to a new community and Asst. ED will be interim ED for the time being. LPA was informed the required documents will be provided to LPA in a timely manner to appoint new Administrator. ED reported her exit date in the community to be 12/08/2023.

LPA and Asst. ED then discussed a current concern regarding family visitation dispute with R1. LPA advised facility to keep documentation and submit incident reports if the events were to reoccur when a resident declined visitation but family members are refusing to leave the premises.

As a result of today's visit, no deficiencies observed.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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