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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400113
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:32:10 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/01/2022 10:32 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:GARDENFACILITY NUMBER:
366400113
ADMINISTRATOR:CHAVAS ANDERSONFACILITY TYPE:
735
ADDRESS:9212 GARDEN STREETTELEPHONE:
(909) 941-4449
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 3DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lisa Ferrell, DSPTIME COMPLETED:
11:00 AM
NARRATIVE
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 Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening occur. The staff are symptom/temperature screening visitors upon entry into the facility. LPA observes that all staff are wearing face masks. LPA is informed that there are no positive cases of Covid-19 at this time. There are three (3) residents reside in the home. Two (2) where present at LPA arrival time.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in infection control. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Emergency food supply is in place. LPA inquired about fit testing and found that the employees have not been fit tested for N95 respirators. Technical assistance provided during this visit.

Based on observations made during today’s inspection, the following deficiency is being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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Document Has Been Signed on 11/01/2022 10:32 AM - It Cannot Be Edited


Created By: Amy Goldenberg On 11/01/2022 at 10:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GARDEN
FACILITY NUMBER: 366400113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
80087(a)

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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The licensee has failed to meet this requirement as evidenced by LPA
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Licensee to fix, repair or replace items mentioned by POC due date. LIC 9098 provided to CCl self certifying that the corrections have been made.
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Observation of a broken table in yard, back office exit door knob is loose, missing and broken kitchen drawers and loose cabinets. broken sliding back door and screen. These items pose a risk to the healths and safety of residents in care.
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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
LICENSING EVALUATOR NAME:Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


LIC809 (FAS) - (06/04)
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