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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802287
Report Date: 04/30/2024
Date Signed: 04/30/2024 12:54:43 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
04/22/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240422232239
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: 13DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:StaffTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff do not properly maintain the facility's electrical outlets
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) De Leon and Rankin conducted a 10-day complaint visit to the facility above. LPA was greeted by care staff and called Administrator. Administrator is at a pre-scheduled appointment and can not met LPA for visit. Administrator will have care staff sign report.

LPA requested a staff roster with telephone numbers and a current resident roster. Administrator will email records to LPA later this afternoon.
LPA's took a physical plant tour of the inside of the facility at 10:25am. LPA's checked several outlets through out the facility and took photographs. Twenty-nine outlets had issues with the cords fitting loosely and the plugs falling out because the contact points start to wear down, Two outlets had the top plug in not working properly, and several outlets had missing or broken covers. Based on LPA's observation and photographs taken the facility this allegation is Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal right printed for care staff.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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 2
Control Number 29-AS-20240422232239
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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2024
Section Cited
CCR
87303(a)
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(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 was not met as evidenced by:
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Administrator agreed to have an electrical company come out to replace outlets not working and replace all cracked or missing covers. Send invoices/receipts to CCL.
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Based on observation and photographs the licensee did not comply with the regulations above several electrical outlets were not working, were loose or covers were broken which poses a potential heath and safety risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
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