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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880886
Report Date: 12/02/2022
Date Signed: 12/02/2022 10:54:06 AM


Document Has Been Signed on 12/02/2022 10:54 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: 5DATE:
12/02/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rosa Santos, Caregiver.TIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA) Amber Coleman and Amy Goldenberg arrived to the facility to conduct a POC visit based on deficiencies issued on 11/16/2022. The facility had failed to meet fire clearance requirements. The facility had retained non-ambulatory residents in second floor ambulatory only bedrooms. POC correction was to be made and a LIC 9098 to be submitted self certifying this correction was received. During this visit LPAs walked through the facility to verify that non-ambulatory residents were moved from the second floor. LPAs did not find any non-ambulatory residents residing on the second floor. In addition, the facility failed to produce complete resident records. POC was to be made by 11/30/2022. LIC 9098 received self certifying that correction was made prior to this visit. LPAs reviewed five (5) resident records. This POC has been met and cleared as a result of this visit.

LPA reviewed a copy of this LIC 809 report with the facility representative and provided a copy during the exit interview.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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