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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603114
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:00:34 PM


Document Has Been Signed on 07/30/2024 03:00 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GARDEN ABODEFACILITY NUMBER:
374603114
ADMINISTRATOR:MELISSA DEUSSENFACILITY TYPE:
740
ADDRESS:17067 COYOTE BUSH DRIVETELEPHONE:
(858) 776-9730
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:6CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Caregiver Maria Latimer TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Maria Latimre. Administrator Melissa Deussen also assisted the LPA over the telephone. The facility was licensed for a capacity six (6), of which two (2) may be bedridden in room # 2. The facility was also approved for a hospice waiver for four (4) residents.

The LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility
was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers 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 resident activities.

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 toxic chemicals/poisons accessible to clients.
Medications were labeled, and stored in a locked area.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, and facility telephone were all working. Fire extinguisher(s) were present. Required licensing postings were observed in visible areas of he facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. The LPA provided technical advise and cited deficiencies in an LIC 809D. A Plan of Correction was jointly formulated with Administrator Melissa Deussen..

An exit interview was conducted with Deussen, to whom a copy of this report, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 07/30/2024 03:00 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GARDEN ABODE
FACILITY NUMBER: 374603114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(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
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Based on interview and review of records, the licensee did not comply with the section cited above in 4 of 4 staff, (S1,S2,S3, and S4). Administrator was not able to produce records for staff, which posed a safety or personal rights risk to persons 4 of 4 persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator agreed to submit complete staff records for S1, S2,S3, and S4, by 8/30/24. Records include staff trainings, clearances, personnel forms, and health screanings.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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