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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803612
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:22:40 AM


Document Has Been Signed on 06/14/2022 11:22 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GARDEN OF EDENFACILITY NUMBER:
486803612
ADMINISTRATOR:MILTON, SHERYLFACILITY TYPE:
740
ADDRESS:115 MENLO COURTTELEPHONE:
(707) 654-8307
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 3DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Steven Milton, LicenseeTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Lead Staff, Octavia Phea. Licensee Steven Milton was contacted and arrived later in the day. The facility currently provides care for 3 residents some of which have a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher were tested and found to be last charged on 6/10/2022 at the time of visit. Both smoke detectors and carbon monoxide detectors were found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility kitchen and garage. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Medications located in hallway were found to be secured. All auditory alarms leading out of the facility send chime to the front door and were all in working order. LPA found individual (I1) living in adjacent in-law unit who has been associated for several years, no longer found to be associated to the facility. LPA reviewed clearance roster and found (I1) last cleared on 3/12/2021. Licensee did not disassociate I1 and was not given any notification of I1 being disassociated from the facility. LPA issued Technical Violation and requested for Licensee to resubmit documentation for re-fingerprint clearance for I1.

Infection Control:
Facility has not submitted a mitigation program plan and has been approved at the time of visit. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms on a daily basis and recorded.

No deficiencies cited during today's visit. Appeal Rights Given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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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