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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880886
Report Date: 05/13/2022
Date Signed: 05/13/2022 10:23:33 AM


Document Has Been Signed on 05/13/2022 10:23 AM - 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: 6DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica Velazquez, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Rohit Lama made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA was greeted and granted entrance by Caregiver Rosa Soto and LPA explained the purpose of today's visit. Administrator, Jessica Velazquez, was contacted and informed of LPA's arrival and arrived shortly after. Prior to entry, Caregiver required LPA to get temperature checked and ensured that LPA was masked. The Administrator stated that all staff and residents were fully vaccinated and there were no recent positive COVID test results nor were there any individuals currently with COVID symptoms.
During today’s visit, LPA made observation pertaining to the facility’s current infection control measures. LPA observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control.
The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and resident for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor resident regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.
LPA Lama reviewed the facility’s COVID-19 training for facility staff and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

CONTINUED ON LIC 809-C

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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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
VISIT DATE: 05/13/2022
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CONTINUED FROM LIC 809

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to the Administrator at the conclusion of the inspection.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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