<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000560
Report Date: 07/21/2023
Date Signed: 07/21/2023 04:19:30 PM

Document Has Been Signed on 07/21/2023 04:19 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:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michelle Santos
Mariles Borja		TIME COMPLETED:
04:35 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) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Mariles Borja and discussed the purpose of the inspection.

During the inspection LPA and Staff Michelle Santos conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and observed the following:

This is a single-story compound consisting of five cottages. Cottage one accommodates (12) clients, cottage two accommodates (4) clients, cottage three accommodates (10) clients and cottage 4 accommodates (6) clients. The fifth cottage is used as staff bedroom with an attached food storage room. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. There is a shaded sitting area. LPA observed clients in their bedrooms and throughout the facility, engaging in leisure activities, such as make-up, coloring, and watching television. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.0-118.5 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in common areas in each client cottage. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be fully charged. Facility appliances were all inspected. One out of five refrigerators was leaking fluid and puddling at the base. One out of five stove burners tested inoperable, and staff attempted to ignite using a grill lighter; a Deficiency was cited on today’s date. Sharps were observed locked in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication carts were observed to be locked and lock is operational. The first aid kit has all the required elements. LPA reviewed six client files and four staff files. LPA interviewed five clients and three staff. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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 3
Document Has Been Signed on 07/21/2023 04:19 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 07/21/2023 at 03:36 PM
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: GARDEN VILLA
FACILITY NUMBER: 306000560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and staff interviews, the licensee did not comply with the section cited above as one out of five stove burners is inoperable, and one out of five fridges was leaking fluid and puddling at the base resulting in brown discoloration, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
1
2
3
4
AD stated they would replace stove and refrigerator and provide LPA with receipt of purchase via email by POC date. AD stated they would provide maintanance staff with an in-service to ensure all appliances are operable at all times and provide LPA with signed and dated in-service by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 07/21/2023
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
Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3