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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603977
Report Date: 06/30/2021
Date Signed: 06/30/2021 12:37:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EDEN GARDEN "C", INC.FACILITY NUMBER:
197603977
ADMINISTRATOR:YADIDI, ROHANGIZFACILITY TYPE:
740
ADDRESS:23601 CANZONET ST.TELEPHONE:
(818) 348-2308
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
06/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rohangiz YadidiTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20201207123537.

During today’s visit, the LPA conducted a physical plant tour and observed the following: at 9:09 a.m., the LPA observed disinfectant and cleaning supplies in a common space. At 9:12 a.m., the LPA observed accessible medications in the office space. At 9:18 a.m., the LPA observed cleaning supplies and bleach on the back porch, along with accessible gardening soil. At 9:24 a.m., the LPA observed unsecured medications in the refrigerator. At 9:26 a.m., the LPA observed accessible cleaning supplies in the common bathroom in the bathtub.

During the file review, the LPA observed the following: out of the six resident files reviewed, four out of six residents (R1, R2, R3, R4) need an updated appraisal. Two out of six residents (R2, R3) need an updated medical assessment.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDEN GARDEN "C", INC.
FACILITY NUMBER: 197603977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2021
Section Cited

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87705(f)(2). Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as disinfectant, gardening supplies, and medications were accessible, which poses an immediate health and safety risk to residents in care.
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Type B
07/12/2021
Section Cited

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87705(c)(5) Care of Persons with Dementia. (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for two out of six residents (R3, R4), as the medical assessment and appraisals were outdated which poses an potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDEN GARDEN "C", INC.
FACILITY NUMBER: 197603977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2021
Section Cited

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87463(c) Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff ... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above for four out of six residents (R1, R2, R3, R4), as the appraisals were outdated, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3