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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600704
Report Date: 06/24/2025
Date Signed: 06/24/2025 06:17:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/24/2025 06:17 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/
DIRECTOR:		GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:188 STARLITE DRIVETELEPHONE:
(650) 212-2674
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 5DATE:
06/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Lolita Factolerin and Smile BranzuelaTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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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. Two 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. Training records and medications may be reviewed at a later date. Ferlene Giusto is a certified RCFE administrator (x 7/25) that oversees facility operations.

The following information is provided to LPA today:
- updated Personnel Report (LIC500)

Proof of current liability insurance to be sent to CCLD BY 7/8/25.

Deficiencies of the California Code of REgulations, Title 22 are cited on a following pages.

See page TWO for Hospice Care Plan requirements.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/24/2025 06:17 PM - It Cannot Be Edited


Created By: Audrey Jeung On 06/24/2025 at 05:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2025
Section Cited
CCR
87355(c)(1)(2)

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CRIMINAL RECORD CLEARANCE
A licensee ...may request a transfer of a criminal record clearance from one state licensed facility to another...state licensed facility by providing the following... to the Dept: signed ... LIC 9182, a copy of the individual's driver's license, or valid ID card issued by the DMV or valid photo
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Criminal record clearances for 3 staff will be transferred to this facility and proof of correction to be sent to CCLD BY DUE DATE.
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ID issued by another state or the U.S. government if the individual is not a CA resident. This requirement is not met, as 3 out of 15 staff do not have criminal record clearance associated to facility. Criminal record clearances for Staff #1, #2, #3 must be transferrred to this facility.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2025 06:17 PM - It Cannot Be Edited


Created By: Audrey Jeung On 06/24/2025 at 05:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2025
Section Cited
CCR
87463(a)

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REAPPRAISALS
The pre-admission appraisa... shall be updated in writing as frequently as necessary or once every 12 months...to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate.
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Reappraisals will be completed for clients #3 and #4 and copies will be sent to CCLD BY DUE DATE
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This requirement is not met, as appraisals for clients #3 and #4--who are diagnosed with dementia--are dated more than 12 months ago. Licensee failed to ensure that appraisals are completed annually, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
07/08/2025
Section Cited
CCR87608(a)(3)

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POSTURAL SUPPORTS
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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MD orders will be sent to CCLD BY DUE DATE for half bed rails for clients #3 and #5
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This requirement is not met, as there are no MD orders maintained for clients #3 and #5, who have half bed rails. This poses a potential health, safety or personal rights risk to clients 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2025 06:17 PM - It Cannot Be Edited


Created By: Audrey Jeung On 06/24/2025 at 05:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2025
Section Cited
CCR
87633(b)

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HOSPICE CARE
See Page 2 for regulation .
This requirement was not met, as ANX hospice care plan for client #1 is incomplete. Licensee failed to ensure that complete hospice care plans are maintained, which poses a potential health, safety or presonal rights risk.
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Complete hospice care plan for client #1 to be sent to CCLD BY DUE DATE.

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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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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
VISIT DATE: 06/24/2025
NARRATIVE
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HOSPICE CARE OF TERMINALLY ILL RESIDENTS
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
(1) The name, office address, business telephone number, and 24-hour emergency telephone number of the hospice agency and the resident's physician.
(2) A description of the services to be provided in the facility by the hospice agency including but not limited to the type and frequency of services to be provided.
(3) Designation of the resident's primary contact person at the hospice agency, and resident's primary and alternate care giver at the facility.
(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.
(A) The plan shall specify all procedures to be implemented by the licensee regarding the storage and handling of medications or other substances, and the maintenance and use of medical supplies, equipment, or appliances.
(B) The plan shall specify, by name or job function, the licensed health care professional on the hospice agency staff who will control and supervise the storage and administration of all controlled drugs (Schedule II - V) for the hospice client. Facility staff can assist hospice residents with self-medications without hospice personnel being present.
(C) The plan shall neither require nor recommend that the licensee or any facility personnel other than a physician or appropriately skilled professional implement any health care procedure which may legally be provided only by a physician or appropriately skilled professional.
(5) A description of all hospice services to be provided or arranged in the facility by persons other than the licensee, facility personnel, or the hospice agency including, but not limited to, clergy and the resident's family members and friends.
(6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan.
(A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control.
(B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.
(7) Any other information deemed necessary by the Department to ensure that the terminally ill resident’s needs for health care, personal care, and supervision are met.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC809 (FAS) - (06/04)
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