198603542-4-7-2022-28-AS-JKAN-CD8UCU-20220406152828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603542
Report Date: 04/06/2022
Date Signed: 04/07/2022 07:40:48 AM

Document Has Been Signed on 04/07/2022 07:40 AM - 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:	GARDENIA GARDEN, INC		FACILITY NUMBER:	198603542
ADMINISTRATOR:	MELIKYAN, SONA		FACILITY TYPE:	740
ADDRESS:	1708 ROYAL OAKS DR.		TELEPHONE:	(626) 772-3050
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	6	CENSUS: 0	DATE:	04/06/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator / Sona Melikyan		TIME COMPLETED:	03:45 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 (LPA) Joe Katrdzhyan conducted an announced pre-licensing visit. LPA met with Administrator / Sona Melikyan for the purpose of conducting a pre-licensing inspection. Licensee / Gardenia Garden, Inc. has submitted an application to operate a Residential Care Facility for the Elderly for a capacity of six (6) residents, ages 60 and over. The facility has an approved fire clearance for five non-ambulatory residents and one bedridden resident. Bedridden resident shall be in bedroom #3. A hospice waiver was approved for six (6) hospice residents only. Dementia care plan was submitted with the plan of operation. Fire clearance was granted on 3/17/22. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The home is located in a residential neighborhood. A tour of the single-story home includes four (4) bedrooms, three and a half (3 1/2) bathrooms, a living room, dining room, kitchen, patio, indoor/outdoor activity areas and a garage. The garage is being used as an office. There is no bedroom designated for Staff/Caregiver. LPA observed a fully equipped living room and a dining room with sufficient dining capacity. Resident bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Resident bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each resident. The bathrooms are clean and operational w/grab bars and non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPA observed an appropriate food supply of seven (7) days of non-perishables. There are no residents living at the facility. The Administrator will purchase fresh perishable foods for a minimum of two days upon licensure. (Please see LIC 809C for additional information)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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 2

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: GARDENIA GARDEN, INC	FACILITY NUMBER: 198603542
	VISIT DATE: 04/06/2022

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
26
27
28
29
30
31
32

Medications and First Aid Kit will be centrally stored and locked in the kitchen cabinet located next to the dishwasher. First aid kit is fully stocked with a manual. Resident and staff records will be centrally stored and locked in the cabinets located in the garage. Facility will not handle resident cash resources. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to residents. Cleaning supplies and dishwashing soap will be stored underneath the kitchen sink making it inaccessible to residents. No firearms will be kept at the facility. The facility smoke/carbon monoxide detectors are hardwired and were tested and operable throughout the facility. LPA observed two (2) fully charged fire extinguisher. There is a functioning telephone on the premises. All exit doors have functioning auditory devices. The hot water temperature was tested and measured within Title 22 Regulations guidelines. The washer and dryer are located inside the garage. According to the Administrator, the garage will be kept unlocked and accessible to residents. All toxins such as cleaning solutions and detergent soap will be locked and stored in the cabinets located inside the garage, making them inaccessible to residents. LPA observed the Emergency Disaster Plan, Personal Rights for Residential Care Facilities for the Elderly and Facility Sketch posted inside the facility as mandated by Title 22 Regulations. The facility has a swimming pool in the back area, which has been fenced in compliance with state and local building codes.

The concerns listed below were observed during today's visit. Corrections are required prior to licensure;

LPA observed two (2) exit gates (located on the east side of the building facing the street) would not self-close due to missing self closing mechanism/latch.
Both screen doors located near the exit from the dining room area were in disrepair and would not close properly.
Privacy locks need to be installed on both shared bathroom doors, connecting to rooms #3 and #4.
The fireplace in bedroom #2 needs to be adequately screened, making it inaccessible to residents.

During todays' visit, LPA reminded the Administrator that prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
Component III was conducted during this visit.
LPA used the inspection tool and the pre-licensing checklist for a Residential Care Facility for the Elderly during this visit.
An exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2