197603977-10-25-2023-29-AS-SURA-CWXUQV-20231025154745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603977
Report Date: 10/25/2023
Date Signed: 10/25/2023 03:48:39 PM

Document Has Been Signed on 10/25/2023 03:48 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EDEN GARDEN "C", INC.		FACILITY NUMBER:	197603977
ADMINISTRATOR:	YADIDI, ROHANGIZ		FACILITY TYPE:	740
ADDRESS:	23601 CANZONET ST.		TELEPHONE:	(818) 348-2308
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rohangiz Yadidi		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA met with the Licensee Rohangiz Yadidi and explained the reason for the visit.

The LPA and the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN/FOOD SERVICE AREA: The facility had a sufficient supply of perishable and non-perishable foods. Knives and sharp items are stored in a locked kitchen cabinet. The entrance to the attached garage was locked. The washer and dryer are located in the garage area. The cleaning supplies are located in the garage area. The facility has a sufficient supply of plates, cups and utensils. The refrigerator and freezer were missing a thermometer, consequently the LPA could not verify the temperature. The refrigerator appeared to be within the approved temperature ranges. The licensee stated that they will purchase the thermometers and will place them in the refrigerator.

COMMON AREAS: The living room area and dining areas are furnished appropriately. The fire extinguisher was last purchased on 10/25/2022 and is located by the kitchen. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed required postings throughout the common space.

BATHROOMS: The residents and staff bathrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 109.5 degrees Fahrenheit.

Continued on LIC 809-C…

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDEN GARDEN "C", INC.	FACILITY NUMBER: 197603977
	VISIT DATE: 10/25/2023

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BEDROOMS: There are five resident bedrooms and one staff bedroom that were furnished and had adequate bedding and linens supplies.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for residents’ use; however, at 12:40 p.m., the LPA and the licensee observed old window blind strips on top of the outdoor table and other items. The table and chairs were dusty and need to be clean. There is a side gate for client use and is single-latched.

RECORDS: Records review began at 2:20 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.

MEDICATIONS: Medications review began at 3:00 p.m.; medications are centrally stored and locked in a cabinet in the garage/office area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil penalties assessed.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/25/2023 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDEN GARDEN "C", INC.	FACILITY NUMBER: 197603977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as many canned and boxed foods were expired as of 2021, 2022, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	POC: Corrected on today's date. Licensee threw away all expired foods.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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