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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601969
Report Date: 05/26/2021
Date Signed: 05/26/2021 02:18:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OAK GARDENFACILITY NUMBER:
198601969
ADMINISTRATOR:LUIS EFREN AGUILARFACILITY TYPE:
740
ADDRESS:246 E. NEWMAN AVENUETELEPHONE:
(626) 358-8230
CITY:ARCADIASTATE: CAZIP CODE:
91006
CAPACITY:6CENSUS: 6DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Laura Aguilar, Co-AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Laura Aguilar, Co-Administrator and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. Facility has submitted a mitigation plan and it is currently under review.

Staff were observed using the visitor assessment procedures. All 4 resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. There is a carbon monoxide detector in the dining room. All bathrooms were toured. Bathrooms have the required grabs bars and non-skid mat. The hot water was 110 degrees which is within the required 105 - 120 degrees. The sinks are stocked with soap, hand sanitizer and paper towels. The kitchen was inspected. There is sufficient perishable and non-perishable food. The refrigerator in the kitchen is well stocked with vegetables and meats. There is fruit on the counter and kitchen cabinets are stocked with canned goods. There is another refrigerator in the garage that has additional food. All the appliances are cleaning and working properly. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a sitting area for residents. Visitors are being allowed to conduct visits inside or outside the home.

LPA reviewed 3 resident files to confirm emergency contact is updated. Staff files were reviewed to confirm staff have health screenings and fingerprint clearances. LPA reviewed 3 residents' medications. Medications are documented and stored properly in locked kitchen cabinets. Co-administrator was notified the annual fees are not current. Co-administrator will follow-up regarding annual licensing fees.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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