361880886-5-23-2024-56-AS-MECA-D5JUHF-20240523153552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880886
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:36:06 PM

Document Has Been Signed on 05/23/2024 03:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GARDEN OF EDEN ASSISTED LIVING		FACILITY NUMBER:	361880886
ADMINISTRATOR:	VELAZQUEZ, JESSICA A		FACILITY TYPE:	740
ADDRESS:	14383 CHAMBERLAIN DR		TELEPHONE:	(442) 242-7702
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92394
CAPACITY:	6	CENSUS: 6	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Rosa Soto-Staff		TIME COMPLETED:	03:55 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 Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met staff, Belen Chavez and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. The facility has 7 resident bedrooms, 3 resident bathrooms, kitchen, dining area, living room, attached garage, and backyard with a shed. LPA completed a walk through of facility, review of records and medication audit with staff, Rosa Soto. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 112 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident files, staff files and medications. There are no guns or ammunition in the facility. Overall, the facility is clean and in good repair. Food Service: Non-perishable and perishable food supply is not sufficient for number of residents in care. Deficiency issued. Dishes, cups, and utensils were stored properly. LPA observed medication stored in the kitchen's refrigerator and garage's refrigerator accessible to residents. Deficiency issued.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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 05/23/2024 03:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in obtaining criminal record clearance for one staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will remove the staff from the schedule and have them submit criminal record clearance. Licensee will submit proof to LPA via email by POC due date.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in making medication accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will purchase a lock box to store refrigerated medication inside the refrigerator. Licensee will submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)(1)(D)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in maintaining an updated/reviewed Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will maintain an updated Infection Control Plan in the facility binder and submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in submitting SIRs to the RO for the hospitalizations, medication errors and falls that occurred to residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will submit a statement of understanding on the regulation cited and submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 03:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in ensuring at least one staff on shift with an active CPR certification which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will submit a statement of understanding on the regulation cited and submit proof to LPA via email by POC due date.

Type B

Section Cited

HSC

1569.618(a)

Other Provisions

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in ensuring that the administrator was present in the facility during normal working hours which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will submit a statement of understanding on the regulation cited and submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 03:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in ensuring that personnel records were maintained complete for all staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will ensure that all staff files are complete and maintained at the facility. Licensee stated that she will submit a statement of understanding to LPA via email by POC due date.

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that the facility had 2 days of perishables and 7 days of nonperishables foods which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will purchase food according to the regulation cited and submit proof of purchase (receipts and grocery photo) to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 03:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in maintaining complete and reviewed/updated resident records in the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will maintain complete and reviewed/updated resident records in the facility. Licensee will submit a statement of understanding to LPA via email by POC due date.

Type B

Section Cited

CCR

87464(f)

Basic Services

Basic services shall at a minimum include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in ensuring that staff were providing basic services like assisting with medication which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will review the MARS for all residents weekly and submit a statement of understanding to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
	VISIT DATE: 05/23/2024

NARRATIVE

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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, and 1 shed used for storage. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed that the Administrator has not been present in the facility during normal working hours. Deficiency issued. LPA observed an expired CPR certification for the only staff present in the facility during inspection. Deficiency issued.

Record Review: LPA reviewed all resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed missing and incomplete resident files. Deficiency issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed missing and incomplete personnel records. Deficiency issued. LPA observed that one staff does not have criminal record clearance. Deficiency with civil penalty issued. Medications were audited at random and appeared to not be dispensed appropriately by staff. Deficiency issued. LPA observed missing SIRs for medication errors, fall incidents and hospitalization incidents. Deficiency issued. LPA observed that the facility did not have a copy of the Infection Control Plan. Deficiency issued. LPA observed an Emergency Disaster Plan not reviewed/updated since 12/3/19. Technical violation issued.

Deficiencies, technical violation and civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to staff, Rosa Soto.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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