197608971-4-19-2022-31-AS-NRED-CDMQPG-20220419122043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608971
Report Date: 04/19/2022
Date Signed: 04/19/2022 12:21:18 PM

Document Has Been Signed on 04/19/2022 12:21 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GARDEN GROVE VILLA		FACILITY NUMBER:	197608971
ADMINISTRATOR:	MORALES, NEIL M.		FACILITY TYPE:	740
ADDRESS:	8051 GARDEN GROVE AVENUE		TELEPHONE:	(818) 514-6274
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 6		CENSUS:	DATE:	04/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Flory Morales		TIME COMPLETED:	12:28 PM

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At approximately 9:50 a.m. on 04/19/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 06/09/2021 for an annual inspection. It is a single story building with 7 bedrooms, 4 bathrooms, kitchen, dining room, office, garage, storage areas, common areas, and outdoor areas. It has an approved fire clearance for 6 non-ambulatory residents, of which 1 may be bedridden. The facility serves residents with dementia. Hospice waivers approved for 2 residents. Surveillance cameras are used at the exterior perimeter.

Census: 6 residents, 4 staff

Entry: Upon entry, LPA observed signs at the front door for the facility’s visitation policy surrounding the COVID-19 pandemic. Postings for COVID precautions, administrator certificate, Ombudsman contact, and Provider Information Notices (PINs) were visible. Near resident bedrooms, LPA observed postings for resident rights, resident councils, house rules, and confidential complaints.

Screening: LPA was screened by staff for symptoms of infectious disease. The screening station contained a digital thermometer, hand sanitizer, surgical masks, and a visitor log. The visitor log recorded contact tracing information, temperature, and time. LPA recommended a column to document symptoms as well.

Bedrooms: The facility has 7 private bedrooms. 1 bedroom is designated as a staff room. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean, odorless, and in good condition.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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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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: GARDEN GROVE VILLA	FACILITY NUMBER: 197608971
	VISIT DATE: 04/19/2022

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Bathrooms: The facility has 4 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 11:42 a.m. LPA measured the water temperature in the shared bathroom to be 105.1 degrees Fahrenheit.

Kitchen: The kitchen contained a freezer, a refrigerator, and two pantries. LPA observed an adequate supply of perishable and non-perishable food. Sharp objects were locked near the stove. Cleaning solutions were locked under the sink. Medication was locked near the kitchen. At approximately 11:15 a.m. LPA observed prepared meals on the table consisting of a sandwich, orange slices, yogurt, and beverage. At 11:51 a.m. LPA measured the refrigerator temperature to be 40 degrees Fahrenheit.

Laundry: The facility has a washer near resident bedrooms. Detergent was locked above the machine. LPA also observed a washer and dryer in the garage.

Garage: The garage was locked from the outside. It contained a washer, dryer, paper supplies, extra water bottles, and detergents.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:16 a.m. LPA measured the living room temperature to be 75.8 degrees Fahrenheit. Seating was arranged in the living room to accommodate physical distancing. Extra linens were kept in a storage closet near Bedroom #1.

Safety: At 10:42 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/16/2021. All emergency exit paths were free from obstructions. Exit gates were unlocked. Emergency Disaster Plan was posted near resident bedrooms. Evacuation routes were clearly labeled. At 11:19 a.m. LPA tested 4 out of 4 smoke detectors to be operational. Smoke detectors were hard wired. At 11:20 a.m. LPA tested the carbon monoxide detector to be operational. LPA heard 4 out of 4 auditory alarms on and functioning during visit.

Outdoor areas: At approximately 9:50 a.m. LPA observed staff maintaining the front yard. All outdoor areas were free from debris. A locked shed was located in the back yard. A resident was smoking under a shaded patio area. All furniture was clean and in good repair.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

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