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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603977
Report Date: 10/18/2022
Date Signed: 10/18/2022 06:43:29 PM


Document Has Been Signed on 10/18/2022 06:43 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, 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:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Rose YadidiTIME COMPLETED:
06:50 PM
NARRATIVE
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Licensing Program Analyst’s (LPA’s) Elsie Campos and Ashley Smith conducted an unannounced Annual Inspection and met with administrator Rose Yadidi. The LPAs explained the reason for the visit. There are currently six residents residing in the facility. When the LPAs arrived, there were six residents and one staff an additional staff arrived shortly thereafter. The LPAs conducted a physical plant tour to ensure there are no health and safety hazards and facility is in compliance.

COMMON AREAS: The living room area and dining areas are furnished appropriately; however, two (2) out of four (4) dining chairs were in disrepair. At the time of the visit the LPA’s witnessed the chairs fall apart. The ceiling fan in the dining room and the air conditioning vent in the living room requires cleaning. The carbon monoxide detector was tested at approximately 2:17 p.m. and was operational. However, two (2) out of five (5) smoke detectors were inoperable and required a replacement battery. The administrator replaced batteries on two smoke detectors at the time of observation. Immediate civil penalty of $500 assessed due to zero tolerance violation. Smoke detectors in resident room #2 and #4 need to be replaced as they were not able to be tested as they are outdated. The fire extinguisher is fully charged however last replaced 8/7/2021. The back yard area is enclosed with a self-latching gate and outdoor seating. There were no bodies of water noted at this time.

KITCHEN/FOOD SERVICE AREA: The facility had a sufficient supply of perishable and non-perishable foods and food was stored at appropriate temperatures. Centrally stored medications were accessible in an unlocked kitchen cabinet at 1:50 p.m. Knives and sharp items are stored in a kitchen cabinet which was observed to be unlocked at 1:57 p.m. The entrance to the attached garage was unlocked and contained accessible cleaning supplies. The facility has a sufficient supply of plates, cups and utensils.

Continued on LIC 809-C
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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Document Has Been Signed on 10/18/2022 06:43 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
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: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms 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 as cleaning supplies were observed accesible in the unlocked garage and knives were also observed accessible in an unlocked kitchen cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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The Licensee agreed to do the following:
1. Immediatley lock all acccesible items and provide proof to CCL no later than 10/19/2022.
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
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Based on observation, the licensee did not comply with the section cited above as two (2) out of five (5) smoke detectors were inoperable, and smoke detectors in resident room #2 and #4 need to be replaced, and the fire extinguishers were outdated, which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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The Licensee agreed to do the follwoing:
1. Immediatley replace the batteries on the smoke detectors and provide proof to CCL no later than 10/19/2022.
2. Replace smoke detectors in room #2 and #4 and provide proof to CCL no later than 10/19/2022.
Immediate civil penalty of $500 assessed due to zero tolerance violation.

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: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2022 06:43 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
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: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 as the centrally stored medication cabinet located in the kitchen was observed to be unlocked with the key attached which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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The Licensee Agreed to do the following:
1. Immediately lock the medications and store the key inaccessible to residents. Provide proof to CCL no later than 10/19/2022.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2022 06:43 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
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: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 as the dining room chairs, the blinds in the kitchen and master bedroom were in disrepair; and, ceiling fan and A/C vent required cleaning which poses a potential health and safety risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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The Licensee agreed to do the following:
1. Discard of the dining room chairs, replace the blinds, and clean the A/C vents, and ceiling fan. Submit a self-certification form confirming that the items were addressed to CCL no later than 10/24/2022.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

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 as the shower drain was in disrepair and the shower floor required cleaning, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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The Licensee agreed to do the following:
1. Repair the shower drain and clean the shower floor. Submit a self-certification form confirming that the items were addressed to CCL no later than 10/24/2022.

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: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2022 06:43 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
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: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(A)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (A) A signed statement regarding their criminal record history as required by Section 87355(d).

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 in [1] out of [3] staff files (S1), as it was missing a completed criminal record statement, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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The Licensee agreed to do the following:
1. Have S1 complete the criminal record statement (LIC508). Submit proof of completion to CCL by 10/24/2022
Section Cited
Reappraisals
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 13


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
VISIT DATE: 10/18/2022
NARRATIVE
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BEDROOMS: There are five resident bedrooms and one staff bedroom that were furnished and had adequate bedding and linens supplies.

BATHROOMS: There is one resident bathroom which required cleaning. The drainage cover in the shower was in disrepair and needs to be replaced. There was a grab bar and non-skid mat. The supply of toilet paper, soap and paper towels was missing however the administrator replenished at the time of observation. At 2:10 p.m., the hot water temperature in the hallway common bathroom measured at 108.5 F degrees.

RESIDENT FILES: All five resident files were reviewed for, but not limited to signed admission agreements, current medical assessments, and current appraisals. Five out of six resident files (R1, R2, R3, R4, R5) had appraisals that needed to be updated, as they were outdated at the time of observation. The Licensee updated the appraisals during the visit. The Licensee claimed that they discussed appraisals with the residents upon completion. One out of six resident files (R1) was missing a signed personal rights form.



STAFF FILES: Three staff files were reviewed for but not limited to health screenings, personnel records and training requirements. One out of three staff (S1) files was missing a criminal record statement.

INFECTION CONTROL: The LPAs observed a central entry point for screening and temperature checks however, the LPAs were not appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol needs improvement. The LPA discussed changes around testing, visitation and vaccine requirements. The facility's procedures as it pertains to infection control are adequate.


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. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 13 of 13