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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880967
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:15:54 PM

Document Has Been Signed on 10/09/2024 12:15 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GARDEN OF EDEN CARE HOMEFACILITY NUMBER:
331880967
ADMINISTRATOR/
DIRECTOR:		HOLMES-OTTO, REGINAFACILITY TYPE:
740
ADDRESS:31241 CASERA COURTTELEPHONE:
(951) 388-6204
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 2DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Licensee, Regina Holmes-OttoTIME VISIT/
INSPECTION COMPLETED:
12:25 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
On 10/9/2024, Licensing Program Analysts (LPAs) Janette Romero and Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA's were greeted and granted entry by Licensee, Regina Holmes-Otto who was informed of the purpose of the visit. The facility has a fire clearance for two (2) ambulatory and four (4) non-ambulatory elderly residents and an approved hospice waiver for four (4). LPAs were informed there is one (1) resident currently receiving hospice services at the facility.

LPAs toured the facility with Licensee and reviewed records. During the tour, LPAs observed the facility is made up of a one (1) story home with three (3) resident bedrooms, one (1) staff room, two (2) resident bathrooms, a living room, dining room, kitchen and attached garage. All resident's bedrooms had required furniture and lighting. LPAs toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is also available for the residents in care. LPAs observed a hallway cabinet filled with clean towels, blankets, and linen, available for the residents. LPAs toured the kitchen and observed the facility has a 2-day supply of perishable foods and more than a 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. LPAs toured the garage and observed an additional refrigerator with perishable foods. LPAs also noted the facility secures additional cleaning solutions, laundry detergent, and disinfectants in the locked garage. Licensee tested one (1) of the smoke alarms/carbon monoxide detectors and LPAs observed it to be operational. LPAs also observed two (2) charged fire extinguishers mounted throughout the facility, last serviced on 8/2/2024. Medications are secured in a locked cabinet stored in the hallway. Exit signs, emergency contact information, resident's personal rights, and complaint information are visibly posted near the entrance.

During today's visit, LPAs did not issue any citations. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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 1