306000560-8-4-2025-22-AS-EBEY-DK8SPH-20250804140309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000560
Report Date: 08/04/2025
Date Signed: 08/04/2025 02:03:23 PM

Document Has Been Signed on 08/04/2025 02:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GARDEN VILLA		FACILITY NUMBER:	306000560
ADMINISTRATOR/ DIRECTOR:	MARILES BORJA		FACILITY TYPE:	735
ADDRESS:	13031-13061 WILSON STREET		TELEPHONE:	(714) 537-1545
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92844
CAPACITY: 32		CENSUS: 29	DATE:	08/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Dennis Mendoz, Office Assitant		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	On July 29, 2025, at 2:00pm, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry into the facility by Direct Support Staff (DSP) Nancy Orozco, Alicia Torres, and Roberta Grande and explained the reason for the visit. The Administrator (AD), Mariles Borja and Assistant Administrator (AA) Dennis Mendoza arrived shortly after to assist during the visit. AD Mariles Borja has an Administrator certificate that expires on April 03, 2025. The facility is licensed for thirty-two (32) clients, six (6) clients may be non-ambulatory. Currently there are twenty-nine (29) clients on census during today's visit. Around 8:30 am, LPA Bentley toured the facility with DSP staff Nancy Orozco and AA Mendoza, later joined to complete the tour. LPA toured the physical plant, checked food service, and the first aid kit. The facility consists of four (4) residential buildings. Five (5) clients reside in The South House, twelve (12) clients reside in The Main House, nine (9) clients reside in The Front House, and three (3) clients reside in The Back House. There is another additional unit on the facility premises that stores the facility food items and the other part is the recreational room for staff and clients. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. First aid kits had all the required elements including tweezers, thermometer, scissors, and manual. Kitchen was inspected. CONTINUE TO LIC809-C....

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

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 08/04/2025 02:03 PM - It Cannot Be Edited

Created By: Eboni Bentley On 08/04/2025 at 01:37 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GARDEN VILLA	FACILITY NUMBER: 306000560
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the administrator did not complete HIV/TB training in the last two years, which poses a potential health risk to persons in care. Administrator stated they were not aware of training requirement.
	POC Due Date: 08/11/2025
	Plan of Correction
1 2 3 4	Administrator stated they will complete the 3 hour HIV and 1 hour TB training and submit proof to LPA by POC due date and will ensure this training every two years moving forward.

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.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

	Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GARDEN VILLA	FACILITY NUMBER: 306000560
	VISIT DATE: 08/04/2025

NARRATIVE

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Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. All client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. The water temperature measured between 106.3 F degrees and 113.5 F degrees throughout the facility. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was inspected. Perishable and non-perishable food supply was observed at time of visit and AD Borja went grocery shopping, as scheduled, later that day. Sharps and toxin substances were observed secured, locked and inaccessible to clients in care.

There were several fire extinguishers mounted and fully charged throughout the facility with a last service date of July 21, 2025. The facility’s last fire drill was conducted on April 29, 2025. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating. Emergency supplies, food and water in the Main House storage unit were observed.

LPA Bentley conducted an audit of five (5) client files (C1-C5), five (5) staff files (S1-S5), and a medication
and medication administration review. Medications are stored in locked carts in each residential building. Medications are being administered by physician order. LPA interviewed five (5) clients regarding their quality of care and spoke with three (3) staff present regarding care provided. P&I Funds were checked and meet department standards.

Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, LIC809-D and appeal rights were provided to Administrator Mariles Borja at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025

LIC809 (FAS) - (06/04)

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