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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003251
Report Date: 03/29/2024
Date Signed: 04/10/2024 01:26:28 PM


Document Has Been Signed on 04/10/2024 01:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ASTORIA GARDENSFACILITY NUMBER:
397003251
ADMINISTRATOR:JAMES HALLFACILITY TYPE:
740
ADDRESS:1960 WEST LOWELLTELEPHONE:
(209) 833-2200
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:77CENSUS: 46DATE:
03/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Akindele OmoleTIME COMPLETED:
11:00 AM
NARRATIVE
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On 03/29/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a Case Management visit. LPA was greeted by Human Resources Director (HDR), Brittany Young and explained the purpose of the visit. LPA asked that HDR Young call the Facility Designated Representative (FDR) that CCL was present at this time.

Current census was 46. A brief interview with FDR was conducted.

The purpose of this visit was in response to a complaint received by the department on 03/04/2024.
It was learned during the course of the complaint investigation that R1 wandered away unattended through the front doors of the facility. It was learned through interviews conducted that the facilities Egress system was not sending signals to the caregivers to inform them that the resident had left the main building. Further investigation showed that the facility learned that the signal system for the front doors was down for some time and needed to be re-calibrated.

Based on the information above, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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Document Has Been Signed on 04/10/2024 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ASTORIA GARDENS
FACILITY NUMBER: 397003251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2024
Section Cited
CCR
87705(j)

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(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This is not met as evidenced by:
Based on observation and interviews, the Licensee did not ensure that the alert system for the front doors were not in working condition.
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Licensee shall ensure that a statement of correction is conducted and sent to the LPA by the POC date. In addition, the Licensee shall ensure that an alternative system shall be put in place. The licensee shall provide a copy of any services rendered to the LPA by the POC date.
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LPA learned during investigation that R1 was able to leave the facility unassisted through the front doors of the facility due to the signal system was not functional and could not send signal to the caregivers at the time of the incident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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