306005807-7-25-2024-22-AS-SHAD-D7HV2N-20240725160324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005807
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:03:32 PM

Document Has Been Signed on 07/25/2024 04:03 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 OF EDEN GUEST HOME		FACILITY NUMBER:	306005807
ADMINISTRATOR:	OLTEANU, CLAUDIA		FACILITY TYPE:	740
ADDRESS:	11661 PURYEAR LANE		TELEPHONE:	(714) 233-5392
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	6	CENSUS: 6	DATE:	07/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Christine Alfaro		TIME COMPLETED:	04:17 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	This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and William Vanegas for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Staff #1 (S1) Christine Alfaro and discussed the purpose of the inspection. Administrator (AD) Claudia Olteanu appeared via telephone. LPAs reviewed Infection Control requirements. At about 2:15PM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, one-story house with attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPAs observed 4 staff and 4 residents present at the facility. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 111 degrees F in the common resident bathroom and 107 in the private resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in kitchen. Toxins: observed locked in the storage closet. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 3:00PM, LPAs reviewed 6 resident files and 4 staff files, interviewed 2 residents and 2 staff, inspected medications for 6 residents, and inspected resident money and ledgers for 6 residents. CONTINUED

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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 07/25/2024 04:03 PM - It Cannot Be Edited

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 OF EDEN GUEST HOME	FACILITY NUMBER: 306005807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87205(b)

Accountability of Licensee Governing Body

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and admission, the licensee corporation is suspended, which poses a potential safety risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated they have already applied to revive the corporation and will submit proof of revival to LPA by POC due date.

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 6 residents, which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated they will execute their own approved admission agreements with all 6 residents and submit proof to LPA by POC due date.

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	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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 OF EDEN GUEST HOME	FACILITY NUMBER: 306005807
	VISIT DATE: 07/25/2024

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During the inspection, LPAs and S1 observed the following: based on documents and admission, the licensee corporation is suspended; and based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 6 residents.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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