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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802287
Report Date: 09/01/2022
Date Signed: 09/02/2022 12:16:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20210505113111
FACILITY NAME:GARDEN VIEW INNFACILITY NUMBER:
405802287
ADMINISTRATOR:KOC DE JONG, DIMFNAFACILITY TYPE:
740
ADDRESS:7105 SAN GABRIEL RDTELEPHONE:
(805) 462-2273
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:15CENSUS: 11DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Cristal Cole/Med TechTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are not properly trained to give medications.
Facility floor is in disrepair.
INVESTIGATION FINDINGS:
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At 12:30pm on 09/01/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA met with Cristal Cole/ MedTec announced the reason for the visit.

As to the allegation of, “Staff are not properly trained to give medications.” Based on documentation, interviews, and written requests for training; on 05/11/2021, 06/18/2021, and 08/16/2022; the written request on LIC9099’s related to this complaint, and additionally a written request of “staff training records/certifications on medication administration” related to a different complaint (29-AS-20210616113119) of a similar allegation on 06/16/2021 in the same time period of this complaint:
-On 05/11/2021, per LIC9099, the request of, “Staff training's…” was made on this report.
-On 06/18/2022, per LIC9099, the request of, “staff training records/certifications on medication administration” was made in a second report, from a different complaint (29-AS-20210616113119).
-On 08/16/2022 per LIC9099 and LIC9099-C, “-All training records for all staff in 2021 that cover the subject of Dementia care, Medications, Feeding, transfer care, feeding assistance, and Hoyer lift training.” was made from both complaints. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20210505113111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287
VISIT DATE: 09/01/2022
NARRATIVE
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No training records were produced by the licensee until the date of 08/19/2022, over a year and three months past the initial request for records. In this submission of training records, the only record of medication training the Licensee submitted was for staff S4 who had: 1 hour of training in, Minimizing Medical Errors, dated 09/17/2021; 1 hour of training in, assisting with self-administration of medication: Guidelines, dated 01/01/2021; 1 hour of training in, Medication Documentation for California, dated 07/19/2022.
All the training listed above was completed after the date of incident related to this complaint, subsequently there is no evidence that any staff was properly trained to administer medications during the time of the allegations to this complaint. Interviews of Staff 1 – 6 confirmed that all staff interviewed passed medication to residents in care and that is a normal practice of the facility. Based on interviews and documentation the allegation of, “Staff are not properly trained to give medication.” Is substantiated at this time.

As to the allegation of, “Facility floor is in disrepair.” It was discovered though documentation, interviews, observations, and photographic evidence that the facility floor is in disrepair. It was observed by Licensing Program Analyst (LPA) Jeffries on 08/16/2022, on the first floor it was observed in the main living/dining/entrance area that several planks of laminate flooring are separating from each other and need repair or replacement. It was observed by LPA on 08/16/2022 that the first bedroom to the right on the first floor also had laminate plank flooring that were separating and in need of repair or placement. On 08/16/2022, LPA observed in the hallway of the first floor several areas where the planking is separated. On 08/16/2022, LPA observed on the second floor kitchen area next to the sink where an attempt to repair the loose laminate planking were screwed in by approximately six wood screws, however the planks were still separated and the floor in an area in front of the sink would fall 1”-3” inches when LPA walked over that area of the floor, approximately 40 square feet of flooring bowed 1”-3” in front of the upstairs sink. On 08/16/2022, LPA observed the floor in the upstairs living room towards the center of the living room would also bow 1”-3” up and down when LPA walked over the described area which is approximately 40 square feet. On 08/16/2022, LPA observed several door thresholds throughout the facility being in disrepair and creating a possible tripping hazard for residents in care.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20210505113111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287
VISIT DATE: 09/01/2022
NARRATIVE
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On 08/16/2022 LPA observed the door to room 3 on the second floor to be very difficult to open and shut due to miss alignment which may be related to the disrepair of the second story floor as there was no observational evidence of the hinges being bent, broken, or dislocated. All areas observed by LPA are supported with photographic evidence. It was also observed by LPA Chavez on 05/11/2021, that a “water puddle and leak of approximately six (6) inches in diameter in downstairs laundry room floor to the right of sink cabinet” as well as “floor is disrepair” in resident’s room, with provided photographic evidence provided. On 06/16/2021, LPA Chavez noted that she observed the same disrepair's, noted on LIC9099. On 08/16/2022, Licensee send by email to LPA a profit Loss summary indicating the cost of repairs and maintenance for the time period of January 2019 through June 2021. The only specific repairs noted each year on this summary were of the laundry machines. The other line items on the summary were building repairs, equipment repairs and building maintenance, however there are no specific repairs noted on this summary in those categories that indicated any floor repairs were made, which is all prior to the time frame of this complaint (April 2021 through July 2021). The only observational repairs made were the 6 wood screws noted by LPA on 08/16/2022. Interviews of Staff (S1-S5) provided no evidence that floor repairs were made to the facility. Due to observations, lack of documentation and interviews, the allegation of, “Facility floor is in disrepair.” Is substantiated at this time.

Exit interview, citation issued, report signed, report and appeal rights emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210505113111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited
HSC
1569.69(a)(2)
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1569.69(a)(2) Employees assisting residents with self-administration of medication; training requirements. (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete six hours of initial training. This training shall consist of two hours of hands-on shadowing training,
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All facility staff who help with medications will be trained in accordance with 1569.69. Training should be scheduled by 9/2/2022 and a training scheduled provided to LPA. Training should be completed by 9/9/2022 and proof of training provided to LPA.
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 which shall be completed prior to assisting with the self-administration of medications, and four hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement was not met as evidenced by:Based on record review,
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the licensee did not comply with the above cited section when staff (S1-S6) did not have documented medication training, which poses an immediate health and safety risk to residents in care.
Type A
09/02/2022
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement
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: Licensee will ensure the facility is safe and in good repair. Licensee will address floor repair and integrity and door thresholds and alignments by scheduling an inspection with an appropriately licensed contractor by 9/2/2022. Licensee can communicate updates regularly to LPA
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 was not met as evidenced by:
Based on observation, the licensee did not comply with the above cited section based on the condition of the floor and door thresholds, which poses a potential safety risk to residents in care.
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 until all issues are fixed.
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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20210505113111

FACILITY NAME:GARDEN VIEW INNFACILITY NUMBER:
405802287
ADMINISTRATOR:KOC DE JONG, DIMFNAFACILITY TYPE:
740
ADDRESS:7105 SAN GABRIEL RDTELEPHONE:
(805) 462-2273
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:15CENSUS: 11DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Cristal Cole/Med TechTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident’s medications are missing.
Facility has mold.
Facility is not being cleaned properly.
INVESTIGATION FINDINGS:
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At am on 09/01/2022, Licensing Program Analyst (LPA) arrived at the facility to deliver final findings to the allegations to this complaint. LPA met with and identified who he was and the reason for the vlist. As to the allegation of, “Resident’s medications are missing.” Based on interviews and documentation there was insufficient evidence to determine any missing medications during the time frame of this complaint, April 2021 through July of 2021. Medication Administration Records reviewed did not show any evidence of medication missed or destroyed for any resident residing in the facility during this time. There were no incident reports of medication missing by the facility during this time period. A physical medication audit was not capable of being conducted to determine an exact medication count during the time of the allegation. All interviews of staff (S1-S5) and residents (R1-R6) were inconclusive of any credible recollection of loss of any medication during this time. Due to lack to evidence, the allegation of, “Resident’s medication are missing.” is unsubstantiated at this time.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210505113111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287
VISIT DATE: 09/01/2022
NARRATIVE
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 As to the allegation of. “Facility has mold.” It was discovered through interviews and observations that the facility was free of mold. Interviews of Staff (S1-S5) did not reveal any credible recollection of mold being present at the facility during the time of April 2021 through July 2021 and during the Licensing Program Analyst (LPA) tour of the facility on 08/16/2022. Due to lack of evidence the allegation of, “Facility has mold.” Is unsubstantiated at this time.

As to the allegation of, “Facility is no being cleaned properly.” On 08/16/2022 visit of LPA Jeffries, there were no visible indications that facility is not being cleaned properly and it could be concluded that the observations on 06/16/2021 pertaining to facility cleanliness could be contributed to facility daily operations and the time of visit. It was discovered through interviews that all employees have secondary duties dedicated to keeping the facility clean and sanitary. Interviews of Staff 1-5 indicated that the staff do have cleaning duties as a secondary job duty. Based on observations and interviews there is not enough evidence to support the allegation of, “Facility is not being cleaned properly.” and is unsubstantiated at this time.

Exit interview, report signed, and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6