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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003800
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:49:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SENIOR GARDENFACILITY NUMBER:
347003800
ADMINISTRATOR:PUNZALAN, E. VICTORIA S.FACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 723-2402
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 3DATE:
09/24/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Victoria Punzalan, LicenseeTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to ensure facility is in compliance with Health and Safety Code ยง1569.38 Posting of licensing reports; disclosure to new residents following the department serving an Accusation on 9/8/2021. LPA met with Manuel Asuncion, caregiver, and explained purpose of inspection. Caregiver contacted current Licensee of Senior Garden, Victoria Punzalan, who arrived at approximately 215 pm. Licensee confirmed there are (3) residents present. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA observed a notice posted in the lobby/entrance area stating that on 9/9/2021 the facility was served with an Accusation from the department. LPA observed the notice to contain the required elements. Licensee stated that all (3) residents/resident representatives were informed verbally and received a notice by mail as well as Ombudsman.

LPA was unable to confirm with any residents that a notice was received recently regarding a licensing matter due to residents either sleeping or having a diagnosis of Dementia or on hospice.

There are no deficiencies cited on this report.

Exit interview. Copy of report emailed to Licensee following inspection due to technical difficulties.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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