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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:03:44 PM


Document Has Been Signed on 09/20/2024 03:03 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:GEORGES, NATASHAFACILITY TYPE:
740
ADDRESS:2426 GARFIELD AVETELEPHONE:
(916) 488-5722
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:325CENSUS: 189DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Executive DirectorTIME COMPLETED:
03:10 PM
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On 9/20/2024, Licensing Program Analysts (LPAs) Cassie Yang and Cassie Mikkelson arrived at the facility to conduct a case management visit regarding a death report the Department received on 09/19/2024.

LPAs met with Executive Director, Natasha Georges and explained the purpose of the visit.

During this visit, LPAs conducted a file review of R1's file and obtained a copy of the following:
  • R1's LIC 602
  • R1's Needs and Assessment
  • R1's Preplacement Assessment
  • R1's POLST
  • R1's Emergency Contact
  • R1's Skilled Nursing Discharged Report


At this time, LPAs are requesting a copy of the following to be emailed to LPA Yang by Monday 09/23/2024:
  • Staff schedule with contact information for 9/17/2024 and 9/18/2024

The following incident is still under review by the Department.

Exit interview 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: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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