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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701030
Report Date: 04/04/2023
Date Signed: 04/04/2023 11:39:25 AM

Document Has Been Signed on 04/04/2023 11:39 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:SUNGARDEN VILLA IVFACILITY NUMBER:
342701030
ADMINISTRATOR:ROBINSON, RUSSELLEFACILITY TYPE:
740
ADDRESS:303 OAK CANYON WAYTELEPHONE:
(916) 904-0221
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 5DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator: Russelle Robinson TIME COMPLETED:
12:00 PM
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On 04/04/2023, Licensing Program Analysts (LPAs) Sarena Keosavang and Ivan Avila, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPAs met with Facility Administrator, Russelle Robison and explained the purpose of the visit. LPAs ensured she used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs was screened by Caregiver.

LPAs and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. Hot water temperature was measured at 108 F. LPAs observed three (3) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPAs reviewed a total of three (3) residents' files and two (2) staff files.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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