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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003429
Report Date: 08/17/2020
Date Signed: 08/17/2020 04:45:36 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: 75DATE:
08/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Susan McClure, Asst Administrator/Dietary MgrTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 8/17/2020 at 8:30am to conduct a health and safety check on the residents. LPA met with Susan McClure and stated the purpose of the visit. LPA and Susan McClure toured the facility to ensure there no areas that would pose a health, safety or personal rights risk to residents in care. Currently, there are 75 residents receiving care and supervision.
Due to Covid 19 Precautionary measures the following was asked and observed during this visit:
Do any residents or staff have the following symptoms: fever, cough, or difficulty breathing that is not associated with a pre-existing condition? No

Did any residents or staff have any contact with a laboratory-confirmed case of COVID-19 in the past 14-days? No

Is any resident or staff being evaluated for COVID-19 by a healthcare worker in a U.S. healthcare setting? Yes

Has any resident or staff traveled within the last 14 days to a country considered to be at high-risk for COVID-19 by the Center for Disease Control’s travel website? No


Has any resident or staff been quarantined for COVID-19 in the past 30 days? Yes

Entry points


PPE stations and practicing throughout facility-Surveillance Screening
Area for donning and dossing
Positive and negative resident areas -Red and Yellow Zones upstairs and downstairs
Social distancing
LPA observed the air conditioning working throughout the facility during this visit. The hot water temperature measured at 120.0*F.
The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
The fire extinguishers, carbon monoxide and smoke detectors were present in the facility. Facility also has a pull alarm system.
LPA observed 2-day perishables and 7-day non-perishables. Facility is utilizing paper products for meals and snacks.
LPA toured a random mount of rooms and did not observe any health and safety concerns during this visit.
Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020
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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