<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601969
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:55:51 PM


Document Has Been Signed on 05/24/2022 12:55 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, 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:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Griselda Cisneros Caregiver
Laura Aguilar Assistant Administrator 		TIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(s) (LPA) Mary Flores and Valeria Maldonado conducted an unannounced annual visit with focus on infection control domain, food, and medication review. LPAs met with Griselda Cisneros caregiver and explained the reason for the visit. Administrator Laura Aguilar Assistant Administrator.

Facility is licensed to served 6 non-ambulatory residents over the age of 60 with a hospice waiver for 6. Facility is a single home in a residential area. Facility has a living room, kitchen, dining room, 4 resident bedrooms, 2 bathrooms, a front porch, and a back yard. No large bodies of water were observed. Facility has a shaded area in the backyard.

LPAs initiated tour of the facility with Griselda Cisneros and continued tour with Laura Aguilar assistant administrator and observed the following:
Smog/Carbon Monoxide detectors are interlace were tested and in working condition. Facility has sound devices in all exit doors. Kitchen was observed storing sufficient food for at least 2 days of perishables and 7 days of non-perishables, sharps and cleaning supplies were locked under kitchen's sink. All resident bedrooms have sufficient lighting, all required furniture and bedding supplies. Bathrooms have grab bars and skid mats, water temperature was tested as follow bathroom #1(B1) tested at 109.3 degrees F. and bathroom #2(B2) tested at 113.5 degrees F. which is within the required 105-120 degrees F. Medications and files were reviewed for all 6 residents, Resident #1(R1),#2(R2), and #3(R3) have a bedridden status on their physician's report. Facility does not have a bedridden clearance on file. Staff files were reviewed for staff #1,#2,#3. All COVID recommendations are being followed. Except for N95 Fit testing for staff. Administrator certificate for Luis Aguilar #6020261740 expiration date: 9/23/22 was observed.
Deficiency was noted on LIC 809D per Title 22 Regulations.


Exit interview was conducted with Laura Aguilar Assistant Administrator and a copy of this report, LIC809D,technical advisory, and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 05/24/2022 12:55 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: OAK GARDEN
FACILITY NUMBER: 198601969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

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 in 3 out of 6 residents, R1,R2,R3 have a bedridden status in their physician's report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
1
2
3
4
Assistant administrator contacted Fire department during the visit and notify of bedridden residents. Fire department schedule an appointment to assit facility with inquiring a bedridden clearance on 5/26/22. Assistant administrator will contact resident physician's by 5/25/22 and obtain appointment for residents status evaluation and submit copies of R1,R2,R3 physician's report by 6/1/22 or LIC 200 to process bedridden clearance for facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5