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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802287
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:03:35 PM


Document Has Been Signed on 10/26/2023 04:03 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: 14DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee DIMFNA KOC DE JONG, TIME COMPLETED:
04:15 PM
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At 11:00am on 10/26/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced annual inspection visit. LPA met with Administrator Dimfna Koc de Jong announced who he was and the reason for the visit. LPA also issued final findings to complaint AS-20220831083830 during this visit.
The facility consists of a two story house on a large property. The first level of the house consists of a dining room, sitting room, office, warming/staff kitchenette, a family room, 5 resident bedrooms and 2 bathrooms. The second level of the house consists of the living room, family room, dining room, main kitchen, laundry room, 4 bedrooms and 2 bathrooms. There is a deck off of the upstairs dining room and a ramp leads outside to the first floor. The facility has a swimming pool and spa that are gated and locked per regulation requirements. There are several outdoor areas with appropriate furniture and shade available. LPA toured facility with Administrator. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. There is a sprinkler system in the ceiling of facility that was last pressure tested by Mid Coast Fire on 04/03/2023.. Fire extinguishers were fully charged. Inside and outside passageways are free from obstruction. The facility temperature was 74 degrees F. Hot water temperature tested and within regulation parameters.. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. Food is stored in proper containers in the refrigerators and freezers. A written disaster and mass casualty plan is readily available located on the facility office wall.
Licensee and LPA conducted a full review of the annual control tools. LPA noted that one Technical Advisory was issued related the findings to the complaint that was derived this day on staff training documentation. No other citations issued during this annual inspection.
Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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