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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608971
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:59:29 PM


Document Has Been Signed on 08/21/2024 03:59 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GARDEN GROVE VILLAFACILITY NUMBER:
197608971
ADMINISTRATOR:MORALES, NEIL M.FACILITY TYPE:
740
ADDRESS:8051 GARDEN GROVE AVENUETELEPHONE:
(818) 448-6852
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
08/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Neil Morales, CaregiverTIME COMPLETED:
04:30 PM
NARRATIVE
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At 12:45 PM, on 08/21/2024, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced case management visit to this facility. LPA met with the staff who granted access to the facility. The Administrator was contacted and LPA disclosed the reason for the visit. Administrator arrived at the facility shortly after. The Administrator had to leave and designated the staff to sign today's report on their behalf.

Today’s case management visit is to follow up on an incident previously reported on 08/15/2024, stating that R1 left the facility unassisted on 08/14/2024, at around 4:00 AM.

LPA conducted an interview with the Administrator and LPA was informed that the Los Angeles Police Department/911 was notified on 08/15/2024, at 10:27AM, and reported missing person. However, when the police came Administrator informed the police that R1 was previously served with an eviction notice on 07/28/2024. The Regional Office did receive an eviction letter on 07/31/2024, but it was determined unlawful because the Administrative did not provide supportive documents. Review of R1's physician's report date on 05/26/2021, revealed that R1 was diagnosed with dementia and was not able to leave the facility unassisted. In addition, Administrator failed to obtain a new physician's report for R1 for the past three years.
Based on the interview and file review of R1 deficiencies will be cited on LIC 809D.

Appeal rights explained.

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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Document Has Been Signed on 08/21/2024 03:59 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: GARDEN GROVE VILLA
FACILITY NUMBER: 197608971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2024
Section Cited
CCR
87705(5)(A)

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Care of Persons with Dementia (5) Each resident with dementia shall have an annual...... as specified in Section 87458, Medical Assessment,,,,,, care needs. (A) ...., changes shall be made in the care and supervision provided.........
This requirement was not met as evidenced by:
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 Administrator will conduct an in service training with all staff and will submit statement of understanding regardng this seciton.
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Based on interviews & record review, the licensee did not ensure that the staff redirected or followed R1 when he left the facility unsupervised which poses a potential health & safety risk to residents in care.
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Type B
08/28/2024
Section Cited
CCR87506(a)

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87506 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
This requirement is not met as evidenced by:
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Administrator agreed to complete and update all four out of four residents records by the POC date.
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Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing signatures, which poses/posed a potential health, safety or personal rights risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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