198603542-5-26-2023-28-AS-ACAN-CS7MBL-20230526092806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603542
Report Date: 05/25/2023
Date Signed: 05/26/2023 09:28:50 AM

Document Has Been Signed on 05/26/2023 09:28 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:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator- MELIKYAN, SONA		TIME COMPLETED:	12:15 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) Ashley Calderon conducted an a 1 year required annual visit. Upon arrival, LPA met with Administrator Sona Melikyan and discussed the purpose of today. LPA Calderon used the Care Inspection Tool to complete today's visit. Currently there are (0) zero residents living at the facility. Facility is licensed to serve residents ages 60 and over, with a capacity of six (6) residents. (5) 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. LPA Calderon alongside with Sona toured the physical plant areas inside and outside premises. 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, where staff and residents files are kept locked, garage is also used as a laundry room and contains locked cabinets with hygiene supplies, and cleaning products. LPA tested hot water throughout the facility, measured at 110.3 Degree F. Resident bedrooms were inspected for appropriate furniture and linen / bedsheets. 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 equipment were in operable condition. Sharps, disinfectants/toxins were locked in kitchen area. 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 before admitting a resident. Continuation on LIC 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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: GARDENIA GARDEN, INC	FACILITY NUMBER: 198603542
	VISIT DATE: 05/25/2023

NARRATIVE

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First Aid Kit fully stocked and manual observed and was centrally stored and locked in the kitchen cabinet. Medication will be stored and locked in kitchen cabinet, no residents living at the facility during time of visit. (0) zero medication reviewed and stored during time of visit.

The facility smoke/carbon monoxide detectors are hardwired and were tested and operable throughout the facility. LPA observed two (2) fully charged fire extinguisher. Last Fire Drill was 2/19/23.

LPA observed required postages: Facility License, Pub475, the Emergency Disaster Plan, Personal Rights for Residential Care Facilities for the Elderly and Facility Sketch posted inside the facility. The facility has a swimming pool in the back area with a fence and it is in compliance with state and local building codes. LPA Calderon alongside with Administrator Sona checked status on Sona's Admin. certification on CCLD website- Administration Certification. Cert # 6058589740 is pending. Administrator Certification Section Dept. is currently backed-up. Upon receiving certification Sona will email a copy to LPA. Liability Insurance expires 3/1/24 and Lease Term ends 9/30/2024.

Facility has a fireplace in bedroom #2 that is adequately screened, making it inaccessible to residents.

LPA Calderon reviewed (2) staff files and (0) zero residents files.

Per California Code of Regulations, Title 22, no deficiencies were observed.

An exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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