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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003429
Report Date: 08/10/2020
Date Signed: 08/10/2020 02:28:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SKY PARK GARDENSFACILITY NUMBER:
347003429
ADMINISTRATOR:SHERRY RICHARDSONFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: DATE:
08/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sherry RichardsonTIME COMPLETED:
02:00 PM
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An informal conference was conducted today in the Sacramento Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to discuss the recent Healthcare Associated Infections visit on 07/30/2020. Present in the meeting is Healthcare Associated Infections (HAI) Surveyor Lori Schaumleffel, Ombudsman Supervisor Sergio Landeros, Ombudsman Kim Chau, Assisted Living Waiver Program, Jennifer Ward Regional, Assisted Living Waiver Program Andrew Chen, Assisted Living Waiver Donna Walker. Assisted living Waiver Program, William Underwood, Sky Park Gardens administrator Sherry Richardson, Manager Krystall Moore, Licensing Program Manager Stephenie Doub, and Licensing Program Analyst, Suong Teh . The informal conference process was explained during this meeting.

The informal conference process was explained during this meeting regarding the HAI recommendations .
The facility has stated they will do the following to achieve continued and substantial compliance::
  • On the first floor, Red Zone will be at the far end of the South Wing.
  • On the first floor, Yellow Zone will be at the far end of the North Wing.
  • Proper fitting of the N95 respirator.

LPA will continue daily contact to the facility until the facility is COVID cleared.

At this time, no deficiencies are cited. An exit interview was conducted with all mentioned representatives via Microsoft Teams and a copy of this report will be provided to the facility via email. A copy must be signed and returned to Community Care Licensing (CCL) and the one copy is to be retained by the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020
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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