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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603542
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:04:14 PM


Document Has Been Signed on 04/09/2024 02:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GARDENIA GARDEN, INCFACILITY NUMBER:
198603542
ADMINISTRATOR:MELIKYAN, SONAFACILITY TYPE:
740
ADDRESS:1708 ROYAL OAKS DR.TELEPHONE:
(626) 772-3050
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:6CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Marebeth Mallare - AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required-1 year visit. LPA met with Marebeth Mallare, Administrator and explained the reason for the visit. The facility cares for residents age range 60 and over. The facility is licensed for (5) non ambulatory, (1) bedridden resident (shall be in bedroom #3), and approved for (6) hospice residents only. There are currently (3) residents on hospice. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A Hospice Waiver for (6) is approved. Liability insurance policy expired on 03/01/2024 and the Administrator has not renewed the policy.The facility does not handle cash resources for the residents. Latest fire drill was conducted on 03/12/2024.
Physical Plant/Environment Safety: The facility is a single story home located in a residential community.
The home consists of living room, dining area, kitchen, (4) resident bedrooms, one of the bedrooms has a fireplace that is adequately screened, (4) bathrooms, back yard with swimming pool that is fenced and inaccessible to residents, and laundry area in the attached garage. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms have the required grabs bars and non-skid materials. At 9:55am, LPA tested hot water temperature which measured at 108.6 deg F in bathroom #1, 110.4 deg F in bathroom #2, 112.4 deg F in bathroom #3 and 105.4 deg F in bathroom #4 which is within the required 105-120 degrees. Resident #3 (R3) and Resident #4 (R4) are both on hospice and observed to have full-length bed rails. Resident #2 is also on hospice and observed to have half bed rail. The resident in room #1 has 3 small dogs that are free to roams around the house. One resident enjoyed talking to and holding the dog. The laundry room is clean and has cleaning supplies inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and are working properly. The common areas such as activity room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. There is also a swimming pool in the backyard Exit doors have auditory devices that were operating at the time of the visit. There are cameras in the front door, backyard, living room, dining area and kitchen. There were no cameras seen in private areas. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The facility has four (4) fully charged fire extinguishers, last serviced on 01/13/2024.
*****CONTINUED ON LIC809-C*****
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542
VISIT DATE: 04/09/2024
NARRATIVE
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Staffing: A total of three (3) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator has completed the required Administrator courses but has not submitted the certification renewal.
Resident Rights-Information: Resident personal rights are posted. Visiting policy is not posted at a location that is visible and accessible to residents and families. Physician orders for use of full/half bed rails were reviewed in residents files. LPA conducted (2) resident interviews.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean and well maintained). Two (2) residents have a special soft diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.
Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Hospice and Home Health Nurses administer oxygen to the residents.
Resident Records-Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Records. Administrator did not have a current and complete medication record for all the residents for the month of April 2024.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents.
Residents with SHN: (3) Residents on hospice requiring oxygen on as need basis but the facility did not have "No smoking-oxygen in use" signs posted on their rooms. Administrator has not reported to the local fire department that oxygen is in use at the facility. Administrator cannot provide proof of staff training on knowledge and use of the oxygen equipment.

Per California Code of Regulations, Title 22, deficiencies were cited and Technical Assistance were issued.
Exit interview conducted with Administrator Marebeth Mallare. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/09/2024 02:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that PRN medications for Resident #1 did not have written order from a physician which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 04/10/2024
Plan of Correction
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Administrator will submit a copy of the physician's orders for all the PRN medications for Resident #1 (R1) to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 04/09/2024 02:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that the liability insurance policy expired on 03/01/2024 and the Administrator has not renewed the policy which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will submit a copy of the valid liability insurance to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that the facility did not have a current and complete medication record for all the residents for the month of April 2024 which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will send the current and completed Medication Administration Records (MARs) for all 4 residents for the month of April 2024 to CCL/LPA by POC due date.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 04/09/2024 02:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator has not reported to the local fire department that oxygen is in use at the facility which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator agreed to call the local fire department to report the use of oxygen in the facility and send proof of correction to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that (3) Residents on hospice requiring oxygen on as need basis but facility did not have "No smoking-oxygen in use" signs posted on their rooms which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will send pictures showing that the "No smoking-oxygen in use" signs have been posted to the residents rooms to CCL/LPA by POC due date.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 04/09/2024 02:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(5)
Oxygen Administration - Gas and Liquid
(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,, the Administrator did not comply with the section cited above in that the Administrator cannot provide proof of staff training on knowledge and use of the oxygen equipment which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will submit proof of training completed by staff regarding knowledge and use of the oxygen equipment to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8