486803612-5-24-2023-21-AS-DTOA-CS5QUE-20230524122838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803612
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:28:41 PM

Document Has Been Signed on 05/24/2023 12:28 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	GARDEN OF EDEN		FACILITY NUMBER:	486803612
ADMINISTRATOR:	MILTON, SHERYL		FACILITY TYPE:	740
ADDRESS:	115 MENLO COURT		TELEPHONE:	(707) 654-8307
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS: 2	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Steven Milton, Licensee		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lead Staff, Octavia Phea. Licensee Steven Milton was contacted and arrived later in the visit. The facility is a single story home licensed for six non-ambulatory residents. The facility currently provides care for 2 residents none of which have a diagnosis of dementia or considered non-ambulatory. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead staff; 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. Water was measured at faucets accessible to residents and measured at 119.8. degrees F which is within regulation. Medications located in hallway were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Facility receives medication deliveries from resident families and direct from pharmacy. Resident were observed interacting with staff in the common area, watching game show television or utilizing the backyard for leisure. There are two emergency exits located in the backyard both of which were found to be unobstructed. All auditory alarms leading out of the facility send chime to the staff bedroom and were all in working order. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 EDEN	FACILITY NUMBER: 486803612
	VISIT DATE: 05/24/2023

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LPA conducted a sample file review for staff and found all staff to have annual staff training on file. LPA also conducted a file review for all residents. Upon review, LPA found that resident (R1) requires an updated Needs & Service Plan completed. There have not been any major changes of condition and R1 has attended physician's visits in the past several months however documents need updating. In addition, resident R2's physician's report and needs & service plan have been completed but were not available in the facility for review. Technical Violation issued.

Licensee, Steven Milton's Administrator Certification 6043136740 is valid through 12/14/2024.

LPA requested the following documents be sent to CCL by COB 6/7/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.
No deficiencies cited during today's visit. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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