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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000560
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:12:50 PM

Document Has Been Signed on 01/24/2024 04:12 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 VILLAFACILITY NUMBER:
306000560
ADMINISTRATOR:MARILES BORJAFACILITY TYPE:
735
ADDRESS:13031-13061 WILSON STREETTELEPHONE:
(714) 537-1545
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 32CENSUS: 32DATE:
01/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mariles BorjaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez conducted this case management visit to follow up on an incident report that was self reported on January 12, 2024. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Mariles Borja, Administrator and explain the nature of the visit. Incident was self reported for client (C1) incident on January 8, 2024.

During today’s visit LPA completed a review of client records and spoke to the Administrator for details of the incident. On January 8, 2024 C1 requested permission to go into the community from January 8-10, 2024. C1 did not return to the facility on the indicated date. Staff called C1 to obtain information on their return, upon no answer staff called Garden Grove Police Department and filed a report. On January 15, 2024 C1 returned to the facility and staff called Garden Grove Police Department with the update. Per records review C1 does not have a responsible party and makes their own decision. On January 15, 2024 upon C1’s return indicated they were moving out. C1 signed a voluntary consent form indicating they were moving out to live with their partner. C1 was discharged and moved out on that date from the facility.

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies.

This report was reviewed with Executive Director and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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Document Has Been Signed on 01/24/2024 04:12 PM - It Cannot Be Edited


Created By: Ruth Martinez On 01/24/2024 at 03:34 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: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
80070(a)

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The licensee shall ensure that a separate, complete, and current record is maintained in the faciity for each client. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the client records for C1 are incomplete, file review revealed thatl
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Administrator stated they provide training to staff in the regulation cited. Administrator to provide proof of traning to LPA by POC due date.
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file was missing LIC603 preplacement appraisal, appraisal needs and services plan, and LIC602 Physicians report which poses a potentialhealth, safety and personal rights risk to persons in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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