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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400113
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:06:41 PM

Document Has Been Signed on 10/12/2021 01:06 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
RIVERSIDE, 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: 2DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lisa Ferrell - StaffTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Crystal Colvin and Licensing Program Manager (LPM) Joel Esquivel arrived at the facility unannounced for the purpose of delivering the findings of the Financial Investigation Audit Report for Resident 1 (R1). LPA Colvin and LPM Esquivel met with staff member Lisa Ferrell and advised them of the purpose of today's visit. Below is a summary of the findings of the Financial Audit:

FINANCIAL AUDIT:

This audit was conducted due possible financial abuse of R1 by prior Administrator/Staff (S1). It was determined that the previous Administrator (S1) assisted R1 with spending their stimulus money to make a few online purchases. The receipts provided to the facility from S1 were incomplete, and therefore, the new Administrator conducted a physical review of R1's property to confirm items reportedly purchased on behalf of R1. Some items were unable to be located, and therefore the Licensee agreed to pay R1 $364.67 for the unaccounted-for items/monies. Evidenced of reimbursement of R1 of the money owed was provided to Community Care Licensing (CCL) and confirmed. Deficiencies are being cited for the previous Administrator's lack of following Title 22 Regulations as well as incomplete records/receipts for expenditures made with R1's funds. Deficiencies cited.

It was additionally discovered through CCL's audit that the Licensee does not have any written policies or procedures in place and failed to make reasonable efforts to safeguard resident funds. The Licensee is ultimately accountable for all activities that occur in the facility as well as for the care and supervision of the residents. Deficiency cited.

LPA Colvin conducted an exit interview with staff Lisa Ferrell and provided a copy of this report, LIC809D, and appeal rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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 10/12/2021 01:06 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/11/2021 at 04:34 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN
FACILITY NUMBER: 366400113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited
CCR
80064(a)(3)

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Administrator - Qualifications and Duties: (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee agrees to create plan to monitor staff including Administrator to ensure all facility policies and procedures are adheared to. Plan to be submitted to LPA Colvin by Plan of Correction date of 10/13/21.
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Based on interviews and record review, the Licensee did not comply with the above regulation with 1 staff member (S1). S1 was found to have not maintained accurate financial logs for R1 and did not ensure safety of R1's money or property. This was an immediate personal rights violation of R1.
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Type A
10/13/2021
Section Cited
CCR80026(h)(1)(B)

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Safeguards for Cash...of Residents: (h) Each licensee shall maintain accurate records...including...the following: (1) Records of clients' cash resources...Supporting receipts for purchases... (B) The store receipt...for purchases made for the client from his/her account. This was not met by:
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Licensee agrees to create a plan for regular self-auditing of resident's funds, logs, and receipts to ensure adequate records are being maintained. Plan of Correction due by 10/13/21.
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Based on record review, the Licensee did not comply with the above regulation with one resident (R1). The Licensee was unable to produce receipts for all purchases made with R1's money, with $364.67 unaccounted for. This was an immediate personal rights violation of R1.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/12/2021 01:06 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/11/2021 at 04:45 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN
FACILITY NUMBER: 366400113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited
CCR
80062(a)

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Accountability: (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement was not met as evidenced by:
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Licensee agrees to create written policies or procedures to help protect residents' cash and property. Licensee to provide adendum to facility's Plan of Operation which incorporates these policies and procedures. Plan of Correction due 10/13/21.
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Based on interviews and record review, the Licensee did not comply with the above regulation with at least one aspect resident care and supervision. The Licensee does not have any written policies or procedures to help protect residents' cash and property. This is a potential personal rights risk to all residents.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
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