300613175-8-26-2024-22-AS-EKIM-D8HPR5-20240826113210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613175
Report Date: 08/26/2024
Date Signed: 08/26/2024 11:32:18 AM

Document Has Been Signed on 08/26/2024 11:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	DIANA'S GARDEN HOME		FACILITY NUMBER:	300613175
ADMINISTRATOR/ DIRECTOR:	LILIAN C. SALMORIN		FACILITY TYPE:	735
ADDRESS:	2613 EAST DIANA PL		TELEPHONE:	(714) 860-4203
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Lilian Salmorin		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

NARRATIVE

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On August 26, 2024 at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with House Manager (HM) Norma Penano. A phone call was made to Administrator (AD) Lilian Salmorin, who joined the visit around 9:15am. LPA Kim explained the purpose of the visit.

The facility is licensed to operate for six (6) ambulatory clients. The facility is a one story structure with a second story loft located in a residential neighborhood. It consists of the following: three (3) client bedrooms, two (2) staff bedrooms, two (2) bathrooms, living area, dining area, kitchen, second story loft, and outside covered patio area.

LPA Kim toured inside and outside of the physical plant with HM Penano. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Client’s rooms were inspected: Client Room 1, Client Room 2, Client Room 3, and Staff room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 115.8 degrees F. A comfortable temperature of 77 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has (1) fire extinguisher that was charged, mounted in the garage, and serviced on August 23, 2024. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-860-4203) remains available. First Aid kit had all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DIANA'S GARDEN HOME	FACILITY NUMBER: 300613175
	VISIT DATE: 08/26/2024

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and clients. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility conducts Fire/Safety Drills quarterly and last conducted on July 22, 2024.

LPA Kim conducted an audit of client files (C1-C6), staff files (S1-S4), and medication and medication administration review. LPA Kim conducted one (1) staff interview and one (1) client interview.

A deficiency was cited issued during this inspection visit as per Title 22 Division 6 Chapter 1 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Lilian Salmorin

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 11:32 AM - It Cannot Be Edited

Created By: Edward Kim On 08/26/2024 at 11:12 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DIANA'S GARDEN HOME	FACILITY NUMBER: 300613175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. LPA observed facility staff member S3 was missing LIC501 and S4 was missing LIC501 and LIC503 from their personnel records.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide CCLD the LIC 501 for S3, and LIC501 and LIC 503 for S4 through email to edward.kim@dss.ca.gov by POC due date September 9, 2024.

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:

Lourdes Montoya

LICENSING EVALUATOR NAME:

Edward Kim

LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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