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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880886
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:55:51 PM


Document Has Been Signed on 11/16/2022 02:55 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:GARDEN OF EDEN ASSISTED LIVINGFACILITY NUMBER:
361880886
ADMINISTRATOR:VELAZQUEZ, JESSICA AFACILITY TYPE:
740
ADDRESS:14383 CHAMBERLAIN DRTELEPHONE:
(442) 242-7702
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY:6CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Jessica Velazquez, Licensee/AdministratorTIME COMPLETED:
03:15 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
Licensing Program Analysts (LPA) Amber Coleman and Amy Goldenberg are conducting this case management visit in conjunction with a complaint investigation. During the course of investigation LPAs investigated concerns regarding fire clearance compliance. This facility received a fire clearance approval for five (5) ambulatory and one (1) bedridden resident. Fire clearance indicates that one bedridden resident may reside in bedroom number six (6) only. During this visit LPAs observed residents upstairs in bedroom #3 (R1) and bedroom #4 (R2) appear to have a non-ambulatory status. LPA reviewed five (5) of five (5) resident records for ambulation status. LPA's learned the following information: Three (3) of five (5) residents records reviewed indicate non-ambulatory status, R1, R2, and R4. This is a violation of their fire clearance approval.

During LPA inspection of the facility LPA observed medications requiring refrigeration unlocked in the bottom drawer accessible to anyone accessing the refrigerator, including residents and those not responsible for dispensing medication. This is a risk to the health and safety of residents in care.

LPAs reviewed five (5) of five (5) resident records. LPA observed that five (5) of five (5) resident records were incomplete.

Based on the aforementioned the following deficiencies are being cited per Title 22, Division 6, of the California code of regulations. See also LIC809D. This report was reviewed with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 3


Document Has Been Signed on 11/16/2022 02:55 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING
FACILITY NUMBER: 361880886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2022
Section Cited

1
2
3
4
5
6
7
All facilities shall maintain a fire clearance approved by...fire department... The facility has failed to meet this requirement as evidenced by the non-ambulatory status, R1, R2, and R4.
8
9
10
11
12
13
14
 This is a violation of the fire clearance approval and poses an immediate risk to the health and safety of those in care.
8
9
10
11
12
13
14
to the first floor bedridden fire cleared room #6. LIC 9098 self certifying that correction has been made to be submited to Community Care Licensing.
Type A
11/16/2022
Section Cited

1
2
3
4
5
6
7
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
8
9
10
11
12
13
14
The facility has failed to meet this requirement as evidenced by: LPA observed refrigerated medication accessible to others. This is a risk to the health and safety of residents in care.
8
9
10
11
12
13
14
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/16/2022 02:55 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING
FACILITY NUMBER: 361880886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2022
Section Cited

1
2
3
4
5
6
7
 The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility....The facility has failed to meet this requirement as evidenced by:
8
9
10
11
12
13
14
LPAs reviewed five (5) of five (5) resident records.L PA observed that five (5) of five (5) resident records were incomplete.
8
9
10
11
12
13
14
emailed to Community Care Licensing.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3