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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603977
Report Date: 10/29/2024
Date Signed: 10/29/2024 04:25:00 PM

Document Has Been Signed on 10/29/2024 04:25 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/
DIRECTOR:		YADIDI, ROHANGIZFACILITY TYPE:
740
ADDRESS:23601 CANZONET ST.TELEPHONE:
(818) 348-2308
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Sara GolfeizTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:10AM. LPAs met with staff. Administrator Sara Golfeiz and Licensee Rohangiz “Rose” Yadidi arrived shortly during the visit. Entrance interview conducted.

Beginning at 10:45AM, the LPAs, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES/AMENITIES: Common areas include the living room and family room. Common areas were appropriately furnished and in good condition. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, and required postings are posted in the entryway.

BEDROOMS: The facility has five (5) bedrooms of which four (4) are designated for single-resident use and one (1) is designated for shared-resident use. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. All bedrooms have exits to the exterior with functioning auditory exit alarms. LPAs observed half bed rails in bedroom #3 at 10:48AM, full bed rails in bedroom #1 at 10:49AM, and half bed rails in bedroom #5 at 11:05AM. Licensee confirmed that the resident in bedroom #1 is not on hospice. Staff replaced the full rails to half rails during the visit. At 12:10PM, LPAs observed the closet by the kitchen being utilized as a staff bedroom. The room is currently permitted as a closet and is not cleared to be used as a bedroom for staff. Per the facility’s fire inspector, the Licensee and Administrator were informed last week that staff cannot stay in the room. Administrator stated that staff will no longer utilize the room since they will be wake-staff. Administrator also stated they are in the process of building a staff room.

Report continued on LIC 809-C.

Kristin HeffernanTELEPHONE: (818) 596-4493
Angela BarutyanTELEPHONE: 747-922-1234
DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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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: 10/29/2024
NARRATIVE
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BATHROOMS: The facility has four (4) bathrooms; three (3) are for resident use and one (1) is for staff use. LPAs observed resident restrooms to be equipped with grab bars near the toilet and shower/tub and non-skid surfaces in the shower/tub. LPAs tested hot water temperatures in resident bathroom and measured within the required range. At 11:10AM, hot water temperature measured at 135.5 degrees Fahrenheit in the staff bathroom, which is above the required range. Administrator and Licensee stated that Resident #1 (R1) uses the staff bathroom. Staff lowered the water heater during the visit.

KITCHEN/GARAGE/LAUNDRY: At 11:12AM, LPAs toured the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. Knives and sharps are stored inaccessible in a locked cabinet. Cleaning supplies are not stored in the kitchen. LPAs observed a fire extinguisher in the kitchen that was fully charged and last purchased 10/19/2024. LPAs toured the locked garage attached to the kitchen. LPAs observed an additional refrigerator/freezer, a washer and dryer, cleaning supplies, and emergency water supply.

EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located directly outside the sliding doors from the living room. No bodies of water were observed on the premises. The facility has a self-latching and self-closing exit gate located on the side passageway.



RECORD REVIEW: Beginning at 10:17AM, LPAs began record review. LPAs continued record review at 11:30AM after physical plant tour. LPAs reviewed six (6) out of six (6) resident and four (4) out of four (4) personnel files for documents including but not limited to: resident bed rail orders, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident files reviewed were missing updated and complete documents. All personnel files observed were missing 20 hours annual training and one (1) out of four (4) was missing valid First Aid training.

MEDICATION REVIEW: Medications are centrally stored in the kitchen and inaccessible. At 2PM, LPAs reviewed medications for three (3) residents. One (1) medication for two (2) residents had missing doses. Administrator stated that Resident #2 (R2) missed their dose due to delays from the pharmacy. Missing morning dose for Resident #3 (R3) could not be accounted for.

Report continued on LIC 809-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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: 10/29/2024
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Licensee stated that emergency disaster drill was conducted last week, however, LPAs were unable to review appropriate documentation.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 10/29/2024 04:25 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as a room not fire cleared is utilized as a staff bedroom which poses an immediate health, safety or personal rights risk.
POC Due Date: 10/30/2024
Plan of Correction
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2
3
4
Administrator stated they will remove the bed from the staff bedroom as there will only be wake-staff from now on. Administrator will submit proof of the empty room and an updated LIC 500 to CCL by 10/30/2024.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on medication review and interview, the licensee did not comply with the section cited above as 2 residents had medications with missing doses which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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2
3
4
Staff administered the missing morning dose for R3 during the visit. Administrator stated they will conduct medication training and submit proof to CCL by 11/05/2024.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 10/29/2024 04:25 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as a non-hospice resident had full bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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2
3
4
Staff replaced the full rails in bedroom #1 to half rails during the visit. Administrator will also obtain physician orders for half rails.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 10/29/2024 04:25 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 water temperature measured at 135.5 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Staff lowered the water heater during the visit. Administrator will submit a 5 day water temperature log to CCL by 11/05/2024.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as all staff files were missing 20 hours annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Administrator stated that staff will complete their 20 hours of annual training and will submit proof to CCL by 11/12/2024.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 10/29/2024 04:25 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: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as 1 out of 4 staff did not have a valid firsr aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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2
3
4
The staff member and Licensee stated that the staff will renew their first aid training and send proof to CCL by 11/05/2024.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as all resident files were incomplete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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