486803612-5-23-2024-21-AS-JMAS-D5JSZS-20240523141938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803612
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:19:46 PM

Document Has Been Signed on 05/23/2024 02:19 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
SANTA ROSA RO, 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:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Octavia Phea, Caregiver & Steven Milton, Administrator		TIME COMPLETED:	02:30 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 and Jacqueline Macias 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. At approximately 10:30am, LPAs toured 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 was tested and found to be last charged on 05/8/2024 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 117. degrees F which is within regulation. LPAs observed fireplace to have no screen and advised Licensee to place a screen (technical advisory issued). 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. LPAs advised Licensee to place an additional auditory alarm in the Living room. Licensee conducts disaster drills on a quarterly basis, however, records do not indicate completion on Feb 2024. During the visit, Licensee, staff, and residents completed disaster drill in compliance with quarterly requirements. Licensee agrees to complete quarterly disaster drills in a timely manner (technical violation issued) continued to 809C...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline Macias	TELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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 05/23/2024 02:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GARDEN OF EDEN	FACILITY NUMBER: 486803612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs and Licensee observation and record review, the licensee did not comply with the section cited above in that R1 did not have an updated Physicians Report, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee to submit a copy of an updated Physicians report of R1 to CCL by plan of correction due date of 6/3/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline Macias	TELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GARDEN OF EDEN	FACILITY NUMBER: 486803612
	VISIT DATE: 05/23/2024

NARRATIVE

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Continued from 809C...

At approximately 11:00am, LPAs conducted a sample file review for staff and found all staff to have annual staff training on file. LPAs also conducted a file review for all residents. Upon review, LPAs found that resident (R1) requires an updated Physicians Report to be completed (deficiency cited, see 809D).

At approximately 12:00pm, LPAs conducted a spot check of medications and found all administering and records to be in order. Medications located in hallway were found to be secured. Facility receives medication deliveries from resident families and direct from pharmacy.

Licensee, Steven Milton's Administrator Certification 7013067740 is valid through 12/14/2024.
Sheryl Milton's Administrator Certification 7010836740 is valid through 3/15/2025

LPA requested the following documents be sent to CCL by COB 6/7/202:

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

Deficiency cited from the California Health & Safety Code, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline Macias	TELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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