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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000560
Report Date: 06/07/2022
Date Signed: 06/07/2022 12:14:05 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/07/2022 12:14 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GARDEN VILLAFACILITY NUMBER:
306000560
ADMINISTRATOR:MARILES BORJAFACILITY TYPE:
735
ADDRESS:13031-13061 WILSON STREETTELEPHONE:
(714) 537-1545
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 32CENSUS: 28DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Michelle Santos, Secretary and Mariles Borja, AdministratorTIME COMPLETED:
12:28 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Secretary Michelle Santos. Administrator Mariles Borja arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to a capacity of (32) thirty two developmentally disabled clients Age range 18-59. (26) twenty six Ambulatory clients and (6) six Non Ambulatory clients. Administrator Mariles Borja has a current Administrator certificate with expiration date of April 3, 2023.

On or about 11:20 am, LPA Rosie Quiroz along with Secretary Michelle Santos and Administrator Mariles Borja began the tour of the inside and outside of the facility. There are (28) clients in care and there are no active COVID-19 cases in the facility. During today's facility inspection, LPA Quiroz observed residents relaxing and resting throughout the facility and in their own cottages. Facility consists of four cottages. Cottage one accommodates (12) clients, cottage two accommodates (4) clients, cottage three accommodates (10) clients and cottage 4 accommodates (6) clients. LPA Quiroz interacted and interviewed with clients during today's visit. Clients present during today's visit appeared to be clean and well taken care of.

LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 75 degrees Fahrenheit.

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within normal limits. Clients bedrooms in four of four cottages appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in storage room behind cottage one readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed seating and shaded area for clients and visitors enjoyment in backyard area. Continued on next page...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GARDEN VILLA
FACILITY NUMBER: 306000560
VISIT DATE: 06/07/2022
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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 17, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated June 17, 2021.

LPA Quiroz was informed that all clients and staff have had their COVID-19 vaccinations and first Booster. Facility indicated to be recording clients temperatures daily.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with Secretary Michelle Santos, and a copy of this report and LIC 811 Confidential Names were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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