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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000560
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:13:22 PM

Document Has Been Signed on 04/25/2024 01:13 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GARDEN VILLAFACILITY NUMBER:
306000560
ADMINISTRATOR/
DIRECTOR:		MARILES BORJAFACILITY TYPE:
735
ADDRESS:13031-13061 WILSON STREETTELEPHONE:
(714) 537-1545
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 32CENSUS: 31DATE:
04/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Marile Borja - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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LPA Dwayne Mason Jr. conducted a case management visit and determined through the Licensing Information System (LIS) and record review that Staff #1 is fingerprint cleared, however Staff #1 is not associated to the facility. Staff #1 has been working at the facility since 1/30/24. A citation is being issued.

LPA observed no other areas of concern during their visit.

Based on today's Case Management visit, one deficiency are being cited. An exit interview was conducted with the Administrator and a copy of this report was provided at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 01:13 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 04/25/2024 at 12:03 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
80065(i)(2)

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Personnel Requirements 80065(i)(2) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)
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AD stated they will fax the background clearance transfer to licensing. AD stated they will email LPA upon completion before the assigned POC due date.

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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:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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