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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608971
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:18:26 PM

Document Has Been Signed on 02/13/2024 03:18 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN GROVE VILLAFACILITY NUMBER:
197608971
ADMINISTRATOR:MORALES, NEIL M.FACILITY TYPE:
740
ADDRESS:8051 GARDEN GROVE AVENUETELEPHONE:
(818) 448-6852
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Neil Morales, AdministratorTIME COMPLETED:
03:40 PM
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At 10:30 AM, Licensing Program Analyst (LPA) Huma Rahimi 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 is a single story building with seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, office, garage, storage areas, common areas, and outdoor areas. It has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility serves residents with dementia. Hospice waivers approved for two (2) residents.

Bedrooms: The facility has seven (7) private bedrooms. One (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.

Bathrooms: The facility has four (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 11:11 AM, LPA measured the water temperature in the shared bathroom to be 119.5 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 in a cabinet next to the kitchen. Medications were locked near the kitchen in a cabinet.

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

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN GROVE VILLA
FACILITY NUMBER: 197608971
VISIT DATE: 02/13/2024
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Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 11:35 A.M. LPA measured the living room temperature to be 72.8 degrees Fahrenheit. Seating was arranged in the living room to accommodate physical distancing. Extra linens were kept in a storage closet between the kitchen and the staff room.

Safety: At 11:45 AM, LPA observed a fully charged fire extinguisher in the kitchen and was purchased on 10/10/2023. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 11:50 AM, . LPA tested four (4) out of four (4) smoke detectors to be operational. Smoke detectors were hard wired. LPA tested the carbon monoxide detector to be operational. LPA heard four (4) out of four (4) auditory alarms on and functioning during visit.

Outdoor areas: At approximately 12:15 PM, LPA observed staff maintaining the front yard. All outdoor areas were free from debris. A locked shed was located in the back yard. All furniture was clean and in good repair.

Between 12:30 PM to 2:00 PM, LPA reviewed records of six (6) residents and four (4) staff. Residents and staff records appeared to be complete and updated.



Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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