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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802287
Report Date: 10/11/2022
Date Signed: 10/11/2022 06:45:22 PM


Document Has Been Signed on 10/11/2022 06:45 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 10DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Dimfna Koc De Jong, Licensee/AdministratorTIME COMPLETED:
07:00 PM
NARRATIVE
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On 10/11/22 at 4:40 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Dimfna Koc De Jong, Licensee/Administrator, and explained the purpose of the visit.

LPA toured the facility with the licensee and observed the following: The facility has infection control signage at the front door upstairs, however, the downstairs entrance did not have signage. Licensee will post infection control/visitor policy signage and send a photo to LPA by 10/12/22. The facility is lacking signage throughout the facility on cough etiquette, handwashing, and use of masks. Licensee will post these signs, take photos, and send to LPA by 10/12/22. Upon entry to the facility, LPA was screened. Licensee did not have CDSS Provider Information Notices (PINs) readily accessible. Licensee will print and post in a common area, take a photo, and send to LPA by 10/18/22. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (4). Fire extinguishers (2) are located upstairs near the laundry room door and downstairs in the laundry room. The extinguishers are fully charged and were inspected on 4/26/22. Licensee states that some residents have dentists listed on their Identification and Emergency Information sheet, and others do not. Licensee will obtain dentist information and update resident Identification and Emergency Information sheets, and email/fax to LPA by 10/18/22. At 4:50 pm, LPA observed chemicals stored in an unlocked cabinet below the sink in the upstairs kitchen, knives/sharps were in an unlocked drawer under the stove in the upstairs kitchen, and chemicals were in an unlocked cabinet in the upstairs hall near resident bedrooms. Deficiency cited.

At 5:30 pm, LPA conducted the Infection Control mitigation module with the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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 10/11/2022 06:45 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
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: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)

87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the above cited section. Chemicals and sharps were stored in unlocked drawers/cabinets which poses an immediate health and safety risk to residents in care.
POC Due Date: 10/12/2022
Plan of Correction
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Licensee will train staff on proper procedures for storing chemicals and knives/sharps and will double-check stored items on a daily basis. Licensee will send a commitment to CCLD by 10/12/22 that the training will be completed by 10/18/22 and then licensee will send a copy of the sign-in sheet with staff names and the topic and date of training to LPA by 10/18/22.
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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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