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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701029
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:42:31 PM

Document Has Been Signed on 05/09/2024 12:42 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SUNGARDEN VILLA VFACILITY NUMBER:
342701029
ADMINISTRATOR/
DIRECTOR:
ROBINSON, RUSSELLEFACILITY TYPE:
740
ADDRESS:304 OAK CANYON WAYTELEPHONE:
(916) 904-0221
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 5DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator- Russelle RobinsonTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 05/09/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak and Associate Governmental Program Analyst (AGPA) Talia Silva arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Administrator Russelle Robinson and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to six (6) resident private bedrooms, one (1) full bathroom and two (2) half bathrooms, kitchen, common areas, and storage area. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, cleaning supplies and knives are locked and inaccessible to residents in care. Hot water temperature was measured at 113.9 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 75 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in the hallway, which was last inspected on 06/05/2023. LPA reviewed drill logs, which are current. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of two (2) personnel and four (4) residents records. All records have the required documents. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR).

No deficiencies are being cited during today's inspection.

Exit interview conducted and copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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