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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808383
Report Date: 06/30/2022
Date Signed: 06/30/2022 05:36:32 PM

Document Has Been Signed on 06/30/2022 05:36 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GARDEN HOUSE ADULT RESIDENTIAL FACILITY, THEFACILITY NUMBER:
370808383
ADMINISTRATOR:GUTIERREZ, LUIS & REBECAFACILITY TYPE:
735
ADDRESS:5640 ALLEGHANY ST.TELEPHONE:
(619) 475-5640
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 4CENSUS: 2DATE:
06/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee, Luis Gutierrez, and Staff, Karina GutierrezTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted a case management visit to cite for a deficiency that was observed during a complaint investigation visit. The LPA identified himself, was granted entry to the facility by Licensee, Luis Gutierrez, and Karina Gutierrez, who the purpose of the visit was disclosed to.

During today's inspection, the LPA observed the following: interior passageways and ramps to be obstructed by cabinets and cleaning supplies. Exterior passageways were obstructed by cabinets, floral pots, buckets, and miscellaneous appliances. Per California Code of Regulations, Title 22, this deficiency was cited in an LIC 809D. A Plan of Correction was jointly formulated with the Licensee.

An exit interview was conducted with Licensee, Luis Gutierrez, to whom a copy of this report, LIC 809D, and Licensee's Rights (LIC 9058 01/16) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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 06/30/2022 05:36 PM - It Cannot Be Edited


Created By: Sabel Martinez On 06/30/2022 at 04:40 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: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited
CCR
80087(c)

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80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
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Licensee has agreed to remove all outdoor and indoor obstructions to passageways, stairways, inclines, ramps, open porches and other areas of potential hazard by 7/30/22.
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Based on observation, the licensee did not maintain interiror and exterior ramps and passage ways free of obtrusctions, to inlcude cabinets, pots, and appliances which poses a potential Health, Safety and Personal Rights risk to 2 of 2 persons 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:Denise Powell
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022


LIC809 (FAS) - (06/04)
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