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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600704
Report Date: 07/11/2024
Date Signed: 07/11/2024 07:56:03 PM


Document Has Been Signed on 07/11/2024 07:56 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ENCHANTED GARDEN FOR SENIORSFACILITY NUMBER:
415600704
ADMINISTRATOR:GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:188 STARLITE DRIVETELEPHONE:
(650) 212-2674
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 6DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lolita Factolerin, Smile Branzuela, Ferlene GiustoTIME COMPLETED:
08:00 PM
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LPA Audrey Jeung toured facility and grounds. This one level facility consists of 5 client rooms--all of which have private half bathrooms and exits--a staff room with one bed, bath/shower room, living and dining rooms, kitchen, and attached 1 car garage. Four residents currently receive hospice services. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. Medications are stored in locked cabinet in dining room. Chemicals and cleaners are stored in garage and locked kitchen cabinet. The backyard is fenced and gated; all bedrooms access wood ramp.

Client and staff records are reviewed. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Ferlene Giusto is a certified RCFE administrator (x 7/25) that oversees facility operations.

The following information is provided to LPA today:

- Updated Disaster and Mass Casualty Plan (LIC610E)
- Current proof of liability insurance for $1 million per incident and $3 million in annual aggregate
- Designation of Facility Responsiblity (LIC308)

Deficiencies of the California Code of REgulations, Title 22 are cited on a following page. See also Technical Advisory Notes--5 pages.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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 07/11/2024 07:56 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ENCHANTED GARDEN FOR SENIORS
FACILITY NUMBER: 415600704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on client record review, the licensee did not comply with the section cited above, as clients #1, #4, #6 are diagnosed with dementia, but appraisals are not updated annually. This poses a potential health, safety or personal rights risk to persons in care.
Appraisal for client #1 dated 2015, client #4 6/2020, client #6 5/23.
POC Due Date: 07/25/2024
Plan of Correction
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Appraisals for clients #1, #4, #6 will be signed and updated. Copies will be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87465(h)(4)
INCIDENTAL MEDICAL CARE

All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation medications for client #2, the licensee did not comply with the section cited above, as staff write start dates and other iinformation on Rx labels. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Staff will cease writing on Rx labels. Plan/proof of correction to be submitted to CCLD BY DUE DATE.
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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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