197606694-8-22-2022-31-AS-MCAA-CHFQ9N-20220819115837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606694
Report Date: 08/19/2022
Date Signed: 08/22/2022 07:33:29 AM

Document Has Been Signed on 08/22/2022 07:33 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DAISY ANNE GARDENS		FACILITY NUMBER:	197606694
ADMINISTRATOR:	ESTELA MONDERIN		FACILITY TYPE:	740
ADDRESS:	20634 KITTRIDGE STREET		TELEPHONE:	(818) 704-4338
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 5		CENSUS: 3	DATE:	08/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Daisy Tajdari		TIME COMPLETED:	12:00 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 Analyst (LPAs) Evelin Rios and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with the administrator, Daisy Tajdari and explained the reason for the visit. At 9:15am, with the assistance of the administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired. There is a carbon monoxide detector located in the hallway that functions properly. The fire extinguisher is located in the kitchen. The charge date is 06/20/2022. The internal temperature is set at 80 degrees at the time of the visit. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were five (5) bedrooms. Four (4) are designated for the residents' use. The one room is for staff. The resident bedrooms in use were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 128 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Passageways and exits were clear of obstruction.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 08/22/2022 07:33 AM - It Cannot Be Edited

Created By: Michael Cava On 08/19/2022 at 11:06 AM

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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DAISY ANNE GARDENS	FACILITY NUMBER: 197606694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by: Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). During the physical plant inspection, hot water in the resident's bathroom was measured at 128 degrees.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	During the visit, the licensee adjusted the hot water to insure it measures between 105 to 120 degrees. No further corrections required at this time.

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:

Eva Miller

LICENSING EVALUATOR NAME:

Michael Cava

LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DAISY ANNE GARDENS	FACILITY NUMBER: 197606694
	VISIT DATE: 08/19/2022

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
26
27
28
29
30
31
32

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. LPAs inspected a shed in the backyard and observed an additional supply of non-perishable canned food sufficient for seven days. There is another refrigerator at the outside with additional perishable food items. The laundry area and detergents is also located outside, on the side of the home.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3