306000560-7-16-2024-22-AS-MTEA-D78RDY-20240716125642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000560
Report Date: 07/16/2024
Date Signed: 07/16/2024 12:57:09 PM

Document Has Been Signed on 07/16/2024 12:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GARDEN VILLA		FACILITY NUMBER:	306000560
ADMINISTRATOR/ DIRECTOR:	MARILES BORJA		FACILITY TYPE:	735
ADDRESS:	13031-13061 WILSON STREET		TELEPHONE:	(714) 537-1545
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92844
CAPACITY: 32		CENSUS: 29	DATE:	07/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:02 AM
MET WITH:	Mariles Borja and Dennis Mendoza		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:02 AM, LPA Tea was greeted and granted entry into the facility by DSP staff, Alicia Torres, Rosa Villegas, and Roberta Grande and explained the reason for the visit. Facility is licensed for 32 clients, six clients may be non-ambulatory. Currently there are twenty nine clients during today's visit. The Administrator, Mariles Borja and administrator in training Dennis Mendoza arrived shortly after to assist during the visit.

At 8:45 AM, LPA Tea reviewed six client files and four staff files. client files and staff files contained all required documentation. Administrator certificate expires on April 03, 2025.

LPA Tea along with the administrator in training Dennis Mendoza and DSP staff Michelle Santos toured the facility at 9:49 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility consist of 4 residential buildings. The South House, houses six clients. The Main House houses 12 clients. The Back House houses one client. The Front House houses ten clients. There is another additional unit on the facility premises that stores the facility food items and the other part is the recreational room for staff and clients. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 105.2 F degrees and 122.0 F degrees. The maintenance technician fixed the water temperature to meet regulation standards while on site in one of the restrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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: GARDEN VILLA	FACILITY NUMBER: 306000560
	VISIT DATE: 07/16/2024

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LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients. Fire extinguishers are fully charged throughout the facility. The facility’s last fire drill was conducted on February 1, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. LPA observed emergency supplies, food and water in the Front House unit. LPA Tea observed clients playing bingo in the Main House and one client knitting. The staff provide outdoor activities and from time to time take clients on outings.

At 10:33 AM LPA reviewed medication storage and administration. Medications are stored in locked carts in each residential building. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

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

This report was reviewed with administrator Mariles Borja and administrator in training Dennis Mendoza and a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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