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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200237
Report Date: 01/07/2025
Date Signed: 01/07/2025 02:01:07 PM

Document Has Been Signed on 01/07/2025 02:01 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GARDEN TRI-VALLEYFACILITY NUMBER:
019200237
ADMINISTRATOR/
DIRECTOR:		HEATHER TAYLOR/WILL SANFORFACILITY TYPE:
775
ADDRESS:676 & 690 L STREETTELEPHONE:
(925) 284-3240
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 20CENSUS: 9DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Ciara Vasquez, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 1/7/2025 at 9:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Personal Wellness Support Lead, Vianey Jaimes and explained the purpose of the visit. Program Coordinator, Ciara Vasquez arrived 30 minutes later.

LPA toured the facility including but not limited to activity rooms, resting room, common areas, bathrooms, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 8/19/2024. Clients bring lunches from home/residential facilities. Hot water temperature in the hallway bathroom was measured at 112.5 degrees F. All observed toilets and hand washing stations are maintained in a safe, sanitary, and operating condition. There are no bodies of water observed. First aid kit was complete. Last disaster drill was conducted on 11/13/2024. LPA reviewed 3 clients and 3 staff files starting at 10:20AM. LPA interviewed 2 staff during inspection.

At 11:53AM, LPA observed unlocked cleaning supplies under the kitchen sink. The lock was broken and unable to lock. Civil penalty of $250 is being assessed for repeat violation.

At 1:29PM, LPA observed S1 does not have health screening or TB test on file during record review.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 01/07/2025 02:01 PM - It Cannot Be Edited


Created By: Grace Luk On 01/07/2025 at 01:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GARDEN TRI-VALLEY
FACILITY NUMBER: 019200237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies and knives which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/08/2025
Plan of Correction
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Program Coordinator has agreed to purchase a new lock for the cabinet and send picture proof to CCLD by POC date. Civil penalty of $250 is being assessed for repeat violation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/07/2025 02:01 PM - It Cannot Be Edited


Created By: Grace Luk On 01/07/2025 at 01:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GARDEN TRI-VALLEY
FACILITY NUMBER: 019200237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test on file for S1 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Program Coordinator has agreed to obtain S1's health screening and TB test and submit a copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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