198603230-1-28-2022-28-AS-BTAO-CB539M-20220128170321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603230
Report Date: 01/28/2022
Date Signed: 01/28/2022 05:04:52 PM

Document Has Been Signed on 01/28/2022 05:04 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:	GARDEN TERRACE SENIOR LIVING		FACILITY NUMBER:	198603230
ADMINISTRATOR:	CHOW, BRUCE		FACILITY TYPE:	740
ADDRESS:	720 N 4TH AVE		TELEPHONE:	(858) 598-3663
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 6		CENSUS: 0	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Bruce Chow, Administrator		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Bruce Chow, Licensee who assisted with visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, approved for six (6) non-ambulatory, of which one (1) may be bedridden. Facility approved for three (3) hospice waivers. Annual fee is current. Administrator certificate is current and the expiration date is 10/26/2023.

During the visit, the infection control domain tool was used, a tour of the facility was conducted and food supply was reviewed. Since no resident was residing at the facility, medications were not reviewed.

The facility is located in a residential neighborhood. A physical tour was conducted. It is a single-story home consisted of three (3) bedrooms, two (2) bathrooms, living room, office area, family room/lounge, kitchen, with an attached garage.

Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 115.5 degrees Fahrenheit which was within Title 22 Regulation guidelines.

(-continued in LIC 809 C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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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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: GARDEN TERRACE SENIOR LIVING	FACILITY NUMBER: 198603230
	VISIT DATE: 01/28/2022

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Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. The residence is equipped with central air conditioning and heating. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers are fully charged.

The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication cabinet with a key lock is located in the kitchen for centrally stored medication and inaccessible to residents. Resident records cabinet with a key lock is located in the office area and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

No deficiencies were cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Licensee /Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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