370808383-10-10-2023-08-AS-DSEA-CWGS8V-20231010133946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808383
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:23:20 PM

Document Has Been Signed on 10/10/2023 04:23 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	GARDEN HOUSE ADULT RESIDENTIAL FACILITY, THE		FACILITY NUMBER:	370808383
ADMINISTRATOR:	GUTIERREZ, LUIS & REBECA		FACILITY TYPE:	735
ADDRESS:	5640 ALLEGHANY ST.		TELEPHONE:	(619) 475-5640
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY: 4		CENSUS: 2	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Luis Gutierrez, Licensee		TIME COMPLETED:	01:48 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) Dawn Segura conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself and was granted entry by Luis Gutierrez, to whom she disclosed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which all must be ambulatory. During today’s inspection, there were a total of two (2) clients in care, of which both were ambulatory. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected the rooms. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, toilet, and shower were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s internal temperature and refrigerator and freezer temperatures were within regulatory range. During today’s visit, LPA observed, via measurement with a thermometer, that hot water temperature at bathroom faucet accessible to clients was out of regulatory range. Water temperature in bathroom which was used by clients initially reached 130 degrees Fahrenheit (F). (Per regulation, hot water at taps accessible to clients is required to be between 105 degrees F and 120 degrees F). Hot water heater was adjusted during the visit, and the water temperature subsequently measured at 126.5 degrees F when measured prior to the end of the visit. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GARDEN HOUSE ADULT RESIDENTIAL FACILITY, THE	FACILITY NUMBER: 370808383
	VISIT DATE: 10/10/2023

NARRATIVE

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required, and stored in locked areas. Confidential records were appropriately stored. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and client present during the visit and reviewed staff and client records. LPA interviews did not raise any licensing concerns. The client files which LPA reviewed contained required documents. Staff records did not contain proof of current first aid training, as the last training for which certification was maintained was on 8/7/2019. Licensee presented proof of current/active business liability insurance; however, licensee was not able to provide proof of a current surety bond, although licensee safeguards client resources.

Deficiencies were cited per California Code of Regulations, Title 22 on the attached LIC 809-D. An exit interview was conducted with Luis Gutierrez, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 04:23 PM - It Cannot Be Edited

Created By: Dawn Segura On 10/10/2023 at 12:56 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GARDEN HOUSE ADULT RESIDENTIAL FACILITY, THE	FACILITY NUMBER: 370808383
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in bathroom used by 2 of 2 clients, which poses a potential safety risk to clients in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Licensee offered to purchase a thermometer, continue to monitor the hot water temperature, adjust the hot water temperature as necessary, and maintain a daily temperature log for a month. The water temperature log will be provided to Community Care Licensing by the POC due date.

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 2 of 2 staff, which poses potential health and safety risks to clients in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Licensee offered to ensure that staff receive current first aid training and will provide proof of training to Community Care Licensing by the 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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dawn Segura

LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/10/2023 04:23 PM - It Cannot Be Edited

Created By: Dawn Segura On 10/10/2023 at 01:03 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GARDEN HOUSE ADULT RESIDENTIAL FACILITY, THE	FACILITY NUMBER: 370808383
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80025(b)

All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records review, the licensee did not comply with the section cited above, which poses a potential personal rights risk to clients in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Licensee offered to obtain a surety bond in the amount of $1,000 and provide proof of current bond to Community Care Licensing by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dawn Segura

LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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