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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801989
Report Date: 02/09/2024
Date Signed: 02/23/2024 02:25:38 PM

Document Has Been Signed on 02/23/2024 02:25 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GARDEN, THEFACILITY NUMBER:
197801989
ADMINISTRATOR:GRAY, ROSLYNFACILITY TYPE:
735
ADDRESS:2485 CEDAR AVE.TELEPHONE:
(562) 492-9833
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 4; 4CENSUS: 1DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:DSP Johnathan C. BartolomeTIME COMPLETED:
04:15 PM
NARRATIVE
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On 02/09/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Direct support personnel Johnathan C. Bartolome as the purpose of the visit was explained. The facility is licensed to serve 4 developmentally disabled clients 18 thru 59 years; ambulatory only, with restricted health conditions. The current census is 1, client is linked to the Harbor regional center. There are no facility fees due at this time.

The facility is a single-story structure located in a residential neighborhood. The home consists of (2) client Bedrooms, (3) Bathrooms (1) staff room, a living room, a kitchen, and a dining-room, and a staff work area. LPA toured the physical plant. All client rooms were checked. Beds and bedding were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. The walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises. Exits and walkways are free of debris/hazards.

LPA conducted a records review of 1 staff record, 1 client record, 1 medication administration record, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 12/01/23, 1 fire extinguisher fully charged and located in the kitchen in area, carbon monoxide and smoke detectors are operational, and landline was observed.

Citation documented on 809D.

Exit interview conducted with Johnathan C. Bartolome, appeal rights explained and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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 02/23/2024 02:25 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 02/09/2024 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GARDEN, THE
FACILITY NUMBER: 197801989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
85064 Adminstrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as LPA did not observe HIV and TB training in Administrators file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
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Administrator will enroll in HIV and TB training and submit proof to LPA by POC due date.

Lizeth.Villegas@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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