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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001365
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:13:42 PM


Document Has Been Signed on 03/25/2022 03:13 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GARDENS, THEFACILITY NUMBER:
515001365
ADMINISTRATOR:PICKARD, CAROLFACILITY TYPE:
740
ADDRESS:840 WASHINGTON AVENUETELEPHONE:
(530) 790-3075
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:49CENSUS: 20DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Carol Pickard, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Mai Thao, arrived at the facility unannounced on 03/25/2022 to conduct a case management visit on an incident that was reported to Licensing on 3/23/2022 and met with Carol Pickard, Administrator. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask.

A suspected abuse report was reported to Licensing on 3/23/2022 alleging that on 3/21/2022 Staff 1 (S1) hit Resident 1 (R1) and Staff 2 (S2) yelled at Resident (R1).

During today's visit, LPA discussed the incident with Administrator, review documents, collected documents, and conducted interviews with Staff and Residents.

Due to the lack of information at this time, follow-up may be needed at a later time.

No citations were observed during this visit.

Exit interview conducted and a copy of this report was left at the facility with Carol Pickard, Administrator.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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